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PSIHIJATRIJADANAS

PSIHIJATRIJADANAS

INSTITUTZA MENTALNO ZDRAVLJE

UDK 616.89

Psihijatrija danas se indeksira u slede im bazama podataka:PsychoInfo; Psychological Abstracts;

Ulrich's International Periodicals Directory, SocioFakt

ć

ISSN-0350-2538

INSTITUTEOF MENTAL HEALTH

PSYCHIATRYTODAY

PSYCHIATRYTODAY

PSIHIJAT. DAN.BEOGRAD,

200 /XXXVII/ / - /5 2 227 380

UDK 616.89 Psihijat. dan. 2005/37/2/227-380/ Bgd. ISSN-0350-2538

PSIHIJATRIJA DANAS

GODINA 37 BEOGRAD BROJ 2, 2005

SADRŽAJ

PREGLEDNI RADOVI

Da li su mentalno obolele osobe sklonije nasilnom ponašanju? /M. Milić................................................................................................................................227

ISTRAŽIVAČKI RADOVI

Prenatalne predstave očeva o privrženosti su prediktivne za vezu oca i deteta od petnaest meseci: australijsko iskustvo /M. Radojević ........................................................................................................................ 257 Povezanost posttraumatskog stresa i kvaliteta života kod građana nakon vazdušnih napada /J. Janković Gavrilović, D. Lečić Toševski, O. Čolović, S. Dimić, V. Šušić, M. Pejović Milovančević, S. Popović Deušić, S. Priebe........................................................ 289 Evaluacija grupne kognitivne psihoterapije posttraumatskog stresnog poremećaja /T. Čavić, M. Pejović............................................................................................................. 307

STRUČNI RADOVI

Likantropija u radovima vizantijskih lekara /V. P. Kontaksakis,†Dž. G. Laskaratos, P. P. Ferentinos, M. V. Kontaksaki, Dž. N. Hristodulu ..................................................................................................................323 Dvojstvo žene /N. Petrović Stefanović, S. Petrović ...................................................................................... 335

Obaveštenja Madridska deklaracija (jun 2005) ......................................................................................... 349 Kalendar kongresa / Website / Publikacije ........................................................................... 357 Uputstva saradnicima ............................................................................................................ 377

UDK 616.89 Psihijat. dan. 2005/37/2/227-380/ Bgd. ISSN-0350-2538

PSYCHIATRY TODAY

YEAR 37 BELGRADE NUMBER 2, 2005

CONTENTS

REVIEW ARTICLES

Are the mentally ill more prone to aggressive behavior? /M. Milic................................................................................................................................ 241

RESEARCH ARTICLES

Prenatal paternal representations of attachment predict of infant-father attachment at 15 months: an Australian study /M. Radojevic ........................................................................................................................ 271 Association of posttraumatic stress and quality of life in civilians after air attacks /J. Jankovic Gavrilovic D. Lecic Tosevski, O. Colovic, S. Dimic, V. Susic, M. Pejovic Milovancevic, S. Popovic Deusic, S. Priebe ....................................................... 297 Evaluation of group cognitive psychotherapy of post-traumatic stress disorder /T. Cavic, M. Pejovic............................................................................................................. 315

GENERAL ARTICLES

Lycanthropy according to Byzantine physicians /V. P. Kontaxakis, †J. G. Lascaratos, P.P. Ferentinos, M. V. Kontaxaki, G. N. Christodoulou .............................................................................................................. 329

Duality of woman /N. Petrovic Stefanovic, S. Petrovic ...................................................................................... 341

Announcements

Declaration of Madrid (June 2005) ....................................................................................... 353

List of Congresses / Website / Publications ......................................................................... 357 Instruction to Contributors .................................................................................................... 377

Psihijat. dan. /2005/37/2/227-240/ Milić M. Da li su mentalno obolele osobe sklonije nasilnom ponašanju?

227

Pregledni rad

UDK: 616.89-008

DA LI SU MENTALNO OBOLELE OSOBE SKLONIJE NASILNOM PONAŠANJU?

Milan Milić

Institut za neuropsihijatrijske bolesti

“Dr Laza Lazarević”, Beograd

Apstrakt: Verovanje u povezanost nasilnosti i mentalnih poremećaja živi u narodima različitih kultura od pamtiveka. Paradoksalno je da ovu povezanost stručnjaci ni danas nisu u potpunosti prihvatili, iako istraživanja u poslednjih petnaest godina jasno ukazuju na njenu ve-rodostojnost. U ovom radu dati su mogući argumenti i predstavljene četiri aktuelne perspekti-ve u sagledavanju ove povezanosti. Najveći deo članka sadrži pregled mnogobrojnih istraživa-nja urađenih na ovu temu u poslednjih petnaest godina, koja su podeljena u tri osnovna meto-dološka pristupa: ispitivanja učestalosti pomenutog ponašanja među pacijentima koji su lečeni, ili se nalaze na lečenju u psihijatrijskim ustanovama; ispitivanja učestalosti mentalnih poreme-ćaja među osobama koje su počinile krivično delo nasilja i nalaze se u ustanovama zatvorskog tipa i, ispitivanja učestalosti kako mentalnih poremećaja, tako i nasilnog ponašanja u uzorku opšte populacije u određenoj društvenoj zajednici. Rezultati većine istraživanja sva tri pristupa skoro ujednačeno ukazuju na značajno viši rizik od nasilnog ponašanja u populaciji psihijatrij-skih pacijenata u odnosu na opštu populaciju, i to posebno kod određenih dijagnostičkih kate-gorija, kao što su poremećaji povezani sa upotrebom psihoaktivnih supstanci, antisocijalni po-remećaj ličnosti, psihotični poremećaji, bipolarni afektivni poremećaj. U zaključku su istaknu-te manjkavosti dosadašnjih istraživanja i pretočene u predlog jednog kvalitetnog nacrta za sle-deća istraživanja na tu temu. Na kraju je naglašena važnost odnosa psihijatara prema ovom osetljivom pitanju, gde bi istraživanje faktora rizika i time preveniranje agresivnosti u ovoj populaciji bili daleko racionalnije od dosadašnjeg neargumentovanog negiranja očiglednog, a opet u službi tih istih pacijenata, jer se upravo prepoznavanjem takvih pojedinaca i pravi razli-ka u odnosu na većinu drugih koji nisu nasilni.

Ključne reči: nasilnost, kriminal, mentalni poremećaji, stigma, epidemiologija


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Uvod Tokom istorije skoro svih poznatih kultura agresivnost i mentalni po-

remećaji (bolesti) su dovođeni u vezu. Sokrat je u jednoj od svojih rasprava komentarisao da broj mentalno obolelih u Atini mora biti nizak, jer ima vrlo malo nasilja [1]. Strah javnosti od duševnih bolesnika je oduvek prisutan i dobro je dokumentovan [2,3,4]. Telefonska anketa obavljena 1990. godine na području cele Amerike pokazuje da 80% učesnika potvrđuje bar jednu od sledećih izjava: mentalno oboleli su skloniji nasilnim radnjama od drugih ljudi; prirodno je plašiti se nekoga ko je duševni bolesnik; važno je imati na umu da bivši pacijenti duševnih bolnica mogu biti opasni [5]. Nasilni akti mentalno obolelih zastrašuju nas više nego neki drugi oblici nasilja. Obič-nom čoveku oni deluju bezumno, nelogično, nepredvidivo, smrtonosno. Čud-no, možda i ironično, ali ovu vezu koja je ljudima poznata vekovima struč-njaci u oblasti mentalnog zdravlja počinju da prihvataju tek nekih deset do petnaest godina unazad. Na pitanje zašto je to tako postoji nekoliko odgovora.

Prvi se odnosi na nedovoljnu uverljivost istraživanja koja su se bavila ispitivanjem veze nasilnog ponašanja i mentalnih bolesti. Validnost takvih istraživanja često je bila ograničena nestandardizovanim ili nejasnim defini-cijama agresivnog (violentnog) ponašanja, mentalnih bolesti, ili oboje; osla-njanjem uglavnom na službene podatke, što vodi u posebnu vrstu zastranji-vanja (videti dalje u tekstu); poređenjem sa osobama koje nisu mentalno obo-lele uz izostavljanje ili manjkavo uključivanje demografskih i situacionih činilaca; i vrstom istraživanja, koja su po pravilu bila retrospektivnog karaktera [1,5,6,7].

Drugo, način na koji se društvo postavlja prema mentalno obolelim agresivnim osobama, varira s vremenom, kako u određenoj kulturi, tako i između različitih kultura. Tu možemo naći vrlo šarolike oblike rešavanja problema, od čuvanja u okviru porodice, preko ignorisanja, smeštaja u bolni-cu, zatvor, pa čak i egzekucije takvih pojedinaca. Do šezdesetih godina dva-desetog veka, rezultati mnogih istraživanja su, oslanjanjem na službene po-datke o stopi hapšenja zbog agresivnog ponašanja, pokazivali da duševno oboleli nisu skloniji nasilnim aktima u odnosu na opštu populaciju [8]. Tada je, međutim, većina pacijenata provodila dobar deo života u raznim ustano-vama. Politika deinstitucionalizacije koja je usledila nakon toga, dovela je do značajnog porasta stope. Pritisak koji je tada počeo u smislu otpuštanja paci-jenata i smanjivanja kapaciteta, mnogima od njih je učinio medveđu uslugu jer su se našli na ulici. Neka istraživanja u Americi pokazuju da su mentalno obolele osobe i, uz to beskućnici, visoko zastupljene među nasilnim prestup-nicima [9]. Osnovnim razlogom smatra se nedostatak adekvatnog psihijatrij-skog lečenja, s obzirom da sami ne dolaze na lečenje, a nemaju porodicu, niti ikoga bliskog ko bi se starao o njima.

Treće, tokom proteklih dvadeset godina, upotreba psihoaktivnih supstanci, kao što su kokain, heroin, halucinogeni, sedativi i druge, zajedno sa alkoholom,


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ušla je na velika vrata u svakodnevicu i dovela do sveopšteg povećanja stope nasi-lja. Naravno da se to odrazilo i na stopu kod mentalno obolelih [10].

Četvrto, psihijatri su opravdano bili oprezni u vezi sa daljom stigma-tizacijom duševno obolelih, sa nečim što je tada delovalo kao vrlo “tanka” priča [8], a postoji i mogućnost zloupotrebe. Neki autori [11] ukazuju da su mentalno oboleli često bili žrtveni jarci, neko na koga je bilo najlakše baciti krivicu u sredinama u kojima je postojao izražen problem nasilja. Na kraju, pretpostavljena opasnost po druge i jeste osnovni uzrok stigme duševno obo-lelih, što onda utiče na sve oblasti njihovog življenja.

U proteklih petnaest godina značajno je porastao broj dokaza o vero-dostojnosti veze duševnih bolesti i nasilnog ponašanja. Oni se ne mogu više ignorisati, niti lako opovrgnuti. Određene nedoumice ipak, još uvek, postoje. S obzirom na nedovoljnu informisanost na tom planu u našim stručnim krugo-vima i javnosti uopšte, sledi pregled epidemioloških radova koji tretiraju pi-tanje odnosa nasilnog ponašanja i mentalnih poremećaja.

Možemo reći da, u celini, među istraživačima postoje četiri perspek-tive u sagledavanju ovog odnosa. Prva, koja danas ima mnogo manje prista-lica nego ranije, ne prihvata nikakvu vezu između mentalnih bolesti i nasilja. Druga tu povezanost prihvata, ali je definiše kao lažnu, kao artefakt. Treće viđenje podržava kauzalnu vezu između nasilja i duševnih bolesti i pokušava da utvrdi šta je to što kod ovakvih bolesti dovodi do nasilja. Najzad, četvrta perspektiva takođe podržava kauzalni odnos, ali ga povezuje sa društvenim prilikama.

Pregled epidemioloških istraživanja Mnogobrojna epidemiološka istraživanja, različito zamišljena, manje

ili više uspešno, dokazivala su ili opovrgavala ove stavove. Nijedna istraži-vačka zamisao nije se pokazala kao idealna. Uopšte uzev, možemo reći da postoje tri osnovna metodološka pristupa u proceni moguće veze između mentalnih poremećaja i nasilničkog ponašanja: prvi, ispitivanje učestalosti pomenutog ponašanja među pacijentima koji su lečeni, ili se nalaze na leče-nju u psihijatrijskim ustanovama; drugi, ispitivanje učestalosti mentalnih po-remećaja među osobama koje su počinile krivično delo nasilja i nalaze se u ustanovama zatvorskog tipa; i treći, ispitivanje učestalosti kako mentalnih poreme-ćaja, tako i nasilnog ponašanja u uzorku opšte populacije u određenoj društvenoj zajednici [12].

Istraživanja prvog metodološkog pristupa Što se tiče prvog pristupa, korišćene su različite strategije u istraživa-

nju: retrospektivna istraživanja psihijatrijski lečenih pacijenata, istraživanja praćenja otpuštenih psihijatrijskih pacijenata, retrospektivna i prospektivna istraživanja psihijatrijskih pacijenata rođenih u određenom vremenskom pe-riodu. Za procenu nasilnog ponašanja uzimani su podaci pre, za vreme ili posle bolničkog lečenja. Svaki od ovih načina procene ima svoje nedostatke,


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i treba ih imati u vidu. Ako su uzimani pre prijema u bolnicu, greška koja često onemogućuje uopštavanje rezultata je upravo to što je razlog prijema uglavnom agitirano ili nasilno ponašanje. Rezultati mogu biti nedostatni i ako se procena vrši za vreme boravka u bolnici, kao i ako se za vreme lečenja agresivno ponašanje koriguje. Sem toga, može se pretpostaviti da se češće leče i hospitalizuju teži duševni poremećaji, kao što je shizofrenija, pa samim tim raste i njihov broj u uzorku. Najzad, validnosti procene nakon otpusta nedostaje to što se pacijenti otpuštaju kada više nisu nasilni. S druge strane, prednost ovakvih istraživanja je što komuniciraju sa zvaničnim podacima pa nisu podložna subjektivnosti. Pored toga, istraživanja rođenih u određenom vremenskom periodu uključuju sve registrovane pacijente, bez obzira na te-žinu oboljenja i broj bolničkih lečenja, te se smatraju najvrednijima u smislu uopštavanja rezultata.

Većina istraživanja ovog metodološkog pristupa nalazi povećan rizik od nasilnog ponašanja kod određenih psihijatrijskih poremećaja. Tako istra-živanja Modestina i Amana [13,14], ispitujući učestalost prekršaja sa nasilni-čkim ponašanjem na populaciji psihijatrijskih pacijenata univerzitetske bol-nice u Bernu, Švajcarska, nalaze tri do četiri puta povećan rizik kod muških pacijenata obolelih od shizofrenije i srodnih bolesti u odnosu na opštu popu-laciju. Retrospektivno istraživanje shizofrenih pacijenata rođenih u Stok-holmu između 1920. i 1959. godine ukazuje na 3.8 puta veći rizik za nasilno ponašanje [15]. Isti rizik nalazi i Vesli sa saradnicima [16] kod muških shizo-frenih pacijenata, koji su prvi put psihijatrijski lečeni, u Londonu, u periodu od 1964. do 1984. godine. Najveći porast rizika od agresivnog ponašanja kod shizofrenih pacijenata nalazi Tihonen sa saradnicima [17]. Prateći kohortu rođenih na severu Finske, oni nalaze da se mogućnost osude zbog prestupa vezanih za nasilničko ponašanje uvećava sedam puta u odnosu na osobe bez psihijatrijskih dijagnoza. Kada se procenjivao rizik kod psihotičnih poreme-ćaja u celini, nađeno je povećanje od četiri puta za muškarce, a za žene i više [18]. Sva istraživanja ovog tipa nalaze izrazito povećan rizik od nasilnog po-našanja kod poremećaja vezanih za upotrebu psihoaktivnih supstanci. Ho-džinsova u već pomenutoj analizi kohorte 15,117 rođenih u Stokholmu, Švedska, nalazi da relativni rizik kod muškaraca sa ovim problemom iznosi 15.4%, dok je u ženskoj populaciji konzumenata taj rizik prisutan kod čak 54.6 % ispitanika [18]. Vidimo da je ta vrednost znatno veća od one kod psi-hotičnih poremećaja. Komparativno istraživanje iste autorke sa saradnicima [19], urađeno u Danskoj, na velikoj neselektivnoj kohorti, dalo je slične re-zultate. Nalaze približne ovima dobili su i drugi istraživači [13]. Za antisoci-jalni poremećaj ličnosti nađen je relativni rizik od 7.2 za muškarce i 12.1 za žene, tj. rizik je toliko puta veći u odnosu na opštu populaciju [19]. Zanimljiv je nešto stariji rad Rapkina, s kraja sedamdesetih [20], u kojom je dat pregled sedam istraživanja stope hapšenih (privođenih) psihijatrijskih pacijenata, gde se pokazalo da istraživanja obavljena pre 1965. godine ne ukazuju na pove-ćanu stopu hapšenja psihijatrijskih pacijenata, za razliku od perioda od 1965.


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do 1979. godine, kada je u svakom istraživanju dobijen suprotan rezultat. Kada se kasnije objavljena istraživanja istog tipa [21,22,23,24] kombinuju sa Rapkinovim pregledom dobije se odnos 3:1 u odnosu na stopu hapšenja –psihijatrijski pacijenti: opšta populacija [25]. Slede Tabele 1. i 2. sa pregle-dom značajnijih istraživanja ovog pristupa.

Tabela 1. Retrospektivna istraživanja pacijenata primljenih na psihijatrijsko le-čenje (prvih pet) i retrospektivna kohortna istraživanja (poslednje dve)

Autori Lokacija Vremenski period

N Pol Dg grupa Definicija agresivnosti

Hamfris i saradnici (1992)

Nortvik Park ? 253 m + ž Sch (ICD-9)

Životno-ugrožavajuće ponašanje (procena rođaka)

Modestin i Aman (1995)

Bern 1987 1,265 m + ž Svi poremećaji (ICD-9)

Službeni podaci (policijski)

Modestin i Aman (1996)

Bern 1985-1987 282 m Sch (RDC) Službeni podaci (sudski)

Volavka i saradnici (1997)

Češka, Danska, Irska, Japan, VB, SAD, ZND Indija, Nigerija

1987 1,017 m Sch (ICD-9)

Fizički napadi (procena drugih)

Mantaner i saradnici (1998)

Baltimor 1983-1989 1,670 m + ž Ppsihoze (DSM-III)

Podaci od ispitanika

Lindkvist i Alebek (1990)

Stokholm 1971-1986 790 m + ž Sch (ICD-8)

Službeni (sudski)

Weseli i saradnici (1994)

London 1964-1984 538 m + ž Sch (ICD-9) Službeni (sudski) i podaci od ispitanika

Tabela 2. Istraživanja praćenja lečenih psihijatrijskih pacijenata (prve tri) i pros-pektivna istraživanja praćenja kohorte rođenih (poslednja četiri)


N Pol Dg grupa Definicija agresivnosti

Svonson i saradnici (1997)

Severna Karolina

1986-1991 169 m + ž Teški mentalni poremećajia

Službeni (bolnica, sud) i od ispitanika

Stidmen i saradnici (1993, 1998)

Pitsburg, Kanzas Siti Vorčester

1992-1995 1,136 m + ž Selekcionisani mentalni poremećajb

Podaci od ispitanika

Švarc i saradnici (1998)

Severna Karolina

? 331 m + ž Teški mentalni poremećajia

Službeni (sud, policija) i od ispitanika

Ortman (1981) Kopenhagen 1953-1978 11,540 m Svi poremećaji

Službeni podaci (sudski)

Hodžins (1992) Stokholm 1953-1983 15,117 m + ž Svi poremećaji

Službeni (sudski)

Hodžinsi i saradnici (1996)

Danska 1944-1947 358,180 m + ž Svi poremećaji

Službeni (sudski)

TIihonen i saradnici (1997)

Severna Finska

1966-1992 12,058 m + ž Svi poremećaji

Službeni (sudski)

a Shizofrenija, paranoidne psihoze, afektivne psihoze b Shizofreni spektar, afektivni spektar, paranoidne psihoze, zloupotreba supstanci


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Tabela 3. prikazuje rezultate nekih od pomenutih istraživanja.

Tabela 3. Relativni rizik od nasilničkog ponašanja kod mentalno obolelih (u od-nosu na opštu populaciju, gde se uzima da je 1.0)

Autori Teški mentalni poremećaji

Organski poremećaji

Shizo-frenija

Afektivni poremećaj

Anksiozni poremećaj

Poremećaji vezani za upotrebu supstanci

Antisoci-jalni pore-mećaj ličnosti

Modestin i Aman, (1995)

m – 3.1 m – 8.8 m – 6.5

Modestin i Aman, (1996)

m – 3.9

Lindkvist i Alebek, (1990)

m – 3.9

Hodžins, (1992)

m – 4.2 ž – 27.4

m – 15.4 ž – 54.6

Hodžins i saradnici, (1996)

m – 4.5 ž – 8.7

m – 2.6 m – 8.7 ž – 15.1

m – 7.2 ž – 12.1

Tihonen i saradnici, (1997)

m – 5.0 m – 7.2 10.4

Svonson i saradnici, (1992)

4.1 1.7 1.2

Stuve i Link, (1997)

3.6a /10.1b

3.3a /6.6b 1.4a /1.5b 1.3a /1.2b

a Rizik od fizičkog napada; b Rizik od korišćenja oružja

Istraživanja drugog metodološkog pristupa Drugi metodološki pristup je zastupljen uglavnom sa dva tipa istraživanja:

onima koja su rađena na prestupnicima koji su počinili ubistvo, i dijagnostička istraživanja reprezentativnog uzorka. Ovako postavljena istraživanja imaju jedan zajednički nedostatak, kao i deo istraživanja prethodnog pristupa, koja analiziraju stopu privođenja psihijatrijskih pacijenata, odnosno da li se psihijatrijski pacijenti ređe ili češće privode tj. hapse. Drugi problem, koji se tiče samo istraživanja ovog tipa, odnosi se na izostavljanje u proceni onog dela psihijatrijskih pacijenata pres-tupnika kojima je izrečena mera lečenja na slobodi. I jedno i drugo uglavnom za-visi od zemlje i njenog zakonodavstva [26,27]. Treća slabost ovog pristupa je što ne uključuje lakše agresivne nastupe, koji najčešće nisu razlog za smeštaj u zatvor-sku ustanovu. Dobra strana ovako osmišljenih istraživanja, slično kao i kod pret-hodnog pristupa, jeste rad sa službenim podacima.

Prvi primer istraživanja sa prestupnicima koji su počinili ubistvo dolazi iz Finske, koja je posebno pogodna za ovakve tipove istraživanja iz dva razloga. Pr-vo, procenat razrešenja ubistava kod njih je vrlo visok, iznosi 97%, i drugo, svaki od prestupnika se detaljno psihijatrijski ispituje. U nekoliko objavljenih radova finski autori, na čelu sa Markom Eronenom, nalaze da je rizik od ubistva osam puta veći kod muškaraca koji boluju od shizofrenije u odnosu na normalnu popu-


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laciju, kod alkoholičara se uvećava više od deset puta, i više od jedanaest puta kod antisocijalnog poremećaja ličnosti, dok afektivni i anksiozni poremećaji ne uveća-vaju relativni rizik [28,29,30]. Tri sledeća istraživanja, dva iz Skandinavije i jedno iz Kanade, takođe ukazuju da među violentnim prestupnicima postoji veliki broj osoba sa težim mentalnim poremećajima. Gotlib i saradnici [31] su, proučavajući ubice u Kopenhagenu između 1959. i 1983. godine, našli da je 20% muškaraca i 44% žena bilo dijagnostikovano kao psihotično. Među njima je 41% muškaraca i 13% žena imalo poremećaj vezan za upotrebu psihoaktivnih supstanci. Rezultati ovog istraživanja pokazuju da se kod psihotičnih osoba rizik od ubistva povećava šest puta za muškarce, i čak šesnaest puta za žene. Sledi Lindkvistovo istraživanje [32] urađeno u Švedskoj na sveukupnoj populaciji osoba koje su počinile ubistvo u periodu od 1970. do 1981. kada je nađeno 53% psihotičnih prestupnika, a među njima 38% poremećaja vezanih za upotrebu psihoaktivnih supstanci. Najzad, kanadsko istraživanje na reprezentativnom uzorku homicidnih prestupnika muškog pola, štićenika zatvora u Kvebeku, ukazuje na značajno veću frek-vencu (35%) težih mentalnih poremećaja (psihoze i teži afektivni poremeća-ji) u odnosu na druge prestupnike iste ustanove. U toj grupi homicidnih pres-tupnika 83% je imalo predistoriju alkoholičarske, a 63% narkomanske zavis-nosti. Interesantna su dalje, u istom kontekstu, istraživanja homicidnih reci-divista. Švedsko istraživanje obavljena na uzorku od dvadeset i jedne osobe koje su počinile ponovljeno delo ubistva, nalazi da su oni često bili vinovnici i drugih nasilničkih ponašanja, i da se većina može svrstati u dijagnostičku grupu poremećaja ličnosti. Mnogi od njih su bili zavisnici od droga i alkoho-la, a 10% je bolovalo od shizofrenije [33]. Tihonen i Hakola [34] su ispitivali trinaest repetitivnih prestupnika ubica, koji su svoj poslednji prestup počinili u poslednje tri godine, i od tada se nalaze u zatvoru ili u nekoj od psihijatrij-skih ustanova sa visokim obezbeđenjem. Kod svih ispitanika je dijagnostiko-vano mentalno oboljenje, i to kod jedanestoro njih težak alkoholizam kombi-novan sa poremećajem ličnosti, a kod dvoje shizofreno oboljenje. Tabela 4. Neka istraživanja prestupnika koji su počinili ubistvo


N Pol Dijagnostički kriterijum

Lindkvist, (1986) Severna Švedska 1970-1981 64 m + ž ? Gotlib i saradnici, (1987) Kopenhagen 1959-1983 263 m + ž ICD-8 Kot i Hodžins, (1992) Kvebek 1988 87 m DSM-III Eronen i saradnici, (1996) a, b

Finska 1984-1991 693 m + ž DSM-III-R


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Tabela 5. Rizik od homicidnog ponašanja među psihijatrijskim pacijentima muš-kog pola u odnosu na opštu populaciju muškaraca

Dijagnoza Stopa na 100 Relativni rizik 95% interval poverenja

Anksiozni poremećaj 1.5 0.3 0.2-0.5 Distimija 1.4 0.6 0.3-1.1 Mentalna retardacija 1.2 1.2 0.9-2.2 Teška depresivna epizoda 3.0 1.6 1.1-2.4 Shizofrenija bez alkoholizma 3.7 7.2 5.4-9.7 Shizofrenija psihotični spektar 6.4 8.0 6.1-10.4 Alkoholizam 39.2 10.7 9.4-12.2 Antisocijalni poremećaji ličnosti 11.3 11.7 9.5-14.4 Alkoholizam i ranije ubistvo 13.3 8.9-20.0 Shizofrenija sa alkoholizmom 2.9 17.2 12.4-23.7 Shizofrenija i ranije ubistvo 25.8 9.6-69.6

Suprotno do sad navedenim istraživanjima, istraživanja reprezentativnog

uzorka opšte populacije štićenika zatvorskih ustanova, tj. učestalosti mentalnih poremećaja u istoj, imaju tu manu što ne prave razliku između nasilnih i nenasil-nih prestupa. Uprkos tom ograničenju i preko njih možemo dobiti nekakvu ori-jentacionu predstavu o odnosu mentalnih oboljenja i nasilnog ponašanja. Kod te zatvorske populacije, posebno ženskog dela, nađena je izrazito povišena stopa alkoholizma, narkomanije i antisocijalnog poremećaja ličnosti u odnosu na opštu populaciju. Često su u komorbiditetu prisutna sva tri poremećaja [35]. O poviše-noj stopi za teže mentalne poremećaje, tipa shizofrenije ili težih afektivnih po-remećaja, a u odnosu na opštu populaciju, izveštava se u više objavljenih istra-živanja na zatvorenicima oba pola [36,37,38]. Za područje naše zemlje ne posto-je ovako ozbiljne epidemiološke analize. Može se reći da, po podacima koji su nama bili dostupni, ne samo u ovom nego i drugim pristupima istraživanju ovog problema, praktično nema značajnijih radova u poslednjih dvadeset do trideset godina. Tabela 6. Dijagnostička istraživanja reprezentativnog uzorka osuđenih prestup-nika (zatvorenika)


N Pol Dijagnostički kriterijum

Tejlor, (1985) London, VB ? 203 m

Hajd i Sajter, (1987) Ohajo, SAD ? 509 m+ž DSM-

Nejbors i saradnici, (1987) Mičigen, SAD 1986 1070 m+ž DSM-III-R

Danijel i saradnici, (1998) Misuri, SAD ? 100 ž DSM-III

Hodžins i Kot, (1990) Kvebek, Kanada 1988 495 m DSM-III

Teplin, (1990) Okrug Kuk, SAD 1983-1984 728 m DSM-III

Harli i Dan, (1991) Brizbejn, Australija 1989 92 ž DSM-III-R

Teplin i saradnici, (1996) Okrug Kuk, SAD 1991-1993 1272 ž DSM-III-R

Džordan i saradnici, (1996) Severna Karolina, SAD

1991-1992 805 ž DSM-III-R


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Tabela 7. Životna učestalost psihijatrijskih poremećaja kod osuđenih prestupnika (zatvorenika) bez selekcije ispitanika po osnovu nasilnost

Dijagnoza Nejbors (1987)

m+ž

Hajd i Sajter

(1987) m+ž

Teplin (1993)

m

Kot i Hodžins

(1990) m

Harli i Dan

(1991) ž

Danijel (1991)

ž

Teplin (1996)

ž

Džordan (1996)

ž

Shizofrenija 2.8 1.5 3.7 6.5 7 2.4

Teška depresija 11.3 12.7 5.7 14.8 19 16.9 13.0

Distimija 6.4 3.0 9.6 7.1

Bipolarni afektiv-ni poremećaj

0.5 0.9 3.4

Manična epizoda 1.1 2.5 2 2.6

Agorafobija 12.0 6

Panični poremećaj

1.6 0.9 2 1.6 5.8

Generalizovani anksiozni poremećaj

22.0 2.5 2.7

Opsesivno kompulzivni poremećaj

5.6 6

Antisocijalni poremećaj ličnosti

50.1 61.5 29 13.8 11.9

Alkoholizam 46.5 28.6 66.9 zajedno 36 32.3 38.6

Narkomanija 28.7 48.9 sa 55.4 26 63.6 44.2

Istraživanja trećeg metodološkog pristupa Poslednji, treći metodološki pristup u istraživanju ove veze, odnosi se

na istraživanja u određenoj društvenoj zajednici (opštini, gradu, regionu). Za procenu se mahom koriste instrumenti tipa upitnika, koje najčešće popunja-vaju sami ispitanici, a ponekad se kombinuju sa zvaničnim podacima o pri-vođenju zbog agresivnih ispada. Ovi tipovi istraživanja imaju nekoliko pred-nosti u odnosu na prethodne. Prva se tiče eliminacije tzv. problema “krimina-lizacije” psihijatrijskih pacijenata, odnosno, disproporcionalnog upućivanja istih na pravosudni sistem u odnosu na opštu populaciju. Druga je slična pr-voj, a odnosi se na tzv. “medikalizaciju” nasilja, tj. na ponekad neadekvatno upućivanje takvih pojedinaca na lečenje, čime se povećava stopa nasilnih pojedinaca među psihijatrijskim pacijentima. I jedna i druga prednost se pos-tižu zahvaljujući nezvaničnim podacima o nasilničkom ponašanju, koji se dobijaju od samih ispitanika. Treća prednost se odnosi na istu sredinu iz koje ispitanici potiču, pa se ne može prigovoriti da je u različitim sredinama takvo ponašanje manje ili više prisutno. Mane ovog pristupa su subjektivnost dobi-jenih podataka i, u nekim istraživanjima, izostavljanje onih pojedinaca koji se nalaze u institucijama (zatvori ili bolnice) zbog ozbiljnijih bolesti ili prestupa.

Do sad su objavljene tri značajna istraživanja ovog pristupa. Prvo is-traživanje o kome ćemo ovde govoriti je urađeno korišćenjem podataka jed-nog šireg američkog epidemiološkog istraživanja (Epidemiologic Catchment Area Study), koje je urađeno na 20,000 ispitanika u pet regiona u Americi, sa ciljem da se odredi broj nelečenih psihijatrijskih poremećaja. Svonson i sa-


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radnici [39] su obrađivali ispitanike iz tri grada: Baltimora, Darama i Los Anđelesa. Evaluirali su podatke dobijene od samih ispitanika, od kojih je tra-ženo da se izjasne da li su u prethodnoj godini (godini koja je prethodila is-traživanju) učinili nešto od sledećeg: udarili supružnika ili partnera, udarili dete toliko da se stvorila modrica ili da se moralo ići lekaru, razmenjivali udarce sa nekim ko nije supružnik ili partner, koristili oružje u tuči, ili se fi-zički obračunavali u pijanom stanju. Osobe sa mentalnim poremećajima su, uopšte uzev, značajno više učestvovale u nekom od pomenutih nasilničkih ponašanja. Za ispitanike sa dijagnozom shizofrenije taj rizik se povećava nešto više od četiri puta (4.1), a najveći rizik od nasilničkog ponašanja nose osobe koje pate od poremećaja vezanih za upotrebu psihoaktivnih supstanci, i on je u ovom istraživanju deset puta veći nego u opštoj populaciji. Grafikon 1. pokazuje pretpostavljenu verovatnoću nasilničkog ponašanja po polu i psi-hijatrijskim dijagnozama, dobijenu metodom logističke regresije u ovom is-traživanju.

Grafikon 1.

0

5

10

15

20

25

Verovatnoća

Bez oboljenja

Anksioznost Afektivni poremećaj Shizofrenija Upotreba

supstanci Upotreba supstanci i mentalni poremećaj

Žene

Muškarci

Drugo istraživanje, koje su sproveli Link i saradnici [5] poredilo je psihijatrijske pacijente i ostale stanovnike Vašington Hajta, dela Njujorka sa etnički i socio-ekonomski vrlo heterogenim stanovništvom, po osnovu više službenih i neslužbenih podataka. Prvi su dobijeni iz policijske dokumentaci-je države Njujork, a drugi preko izjava koje su davali sami ispitanici. Tokom formiranja uzorka populacija psihijatrijskih pacijenata podeljena je u tri gru-pe: oni koji su imali prvi kontakt sa psihijatrijom u godini koja je prethodila in-tervjuu, oni koji su lečeni ranije, ali su bili na tretmanu i u godini koja je pretho-dila istraživanju i, najzad, oni koji su lečeni ranije, ali ne i u protekloj godini. Poređenjem sa zdravom populacijom, u grupi psihijatrijskih pacijenata nađena je značajno viša stopa privođenja zbog nasilnog ponašanja, i to kako po zvaničnim, tako i po podacima koje su davali sami ispitanici, zatim viša stopa fizičkih napa-da na druge, tučâ, korišćenja oružja, teških povreda nanesenih drugima. Vre-menske koordinate su bile ili “do sada u životu”, ili u “poslednjih pet godina”. Dobijene razlike su opstale i posle stroge kontrole sociodemografskih činilaca. Najubedljiviju korelaciju sa nasilničkim ponašanjem kod psihijatrijskih pacijena-ta pokazala je psihotična simptomatologija. Ovakav rezultat, po mišljenju autora, podržava verodostojnost veze nasilničkog ponašanja i duševnih bolesti.


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Trećim istraživanjem [40] autori su pokušali da daju odgovor na neka pi-tanja koja su ili nedovoljno obrađena, ili su promakla u prethodna dva. Jedno od tih pitanja je da li većina mentalnih oboljenja pozitivno korelira sa nasilničkim ponašanjem ili je ono ograničeno na određene komplekse simptoma ili specifične poremećaje. Sledeće se odnosi na mogućnost da veći deo ove povezanosti može biti pripisan specifičnim kontekstualnim činiocima, npr. da li je u toj određenoj društvenoj zajednici interpersonalna agresivnost u rešavanju sukoba uobičajena ili ne. Poslednja dilema se tiče pretpostavke da se nasilničko ponašanje kod mentalno obolelih može u celini objasniti komorbiditetom sa zloupotrebom psihoaktivnih supstanci i antisocijalnim poremećajem ličnosti. Istraživanje je obavljeno u Izraelu na 2,741 ispitaniku, starosti od 24-33 godine, korišćenjem istih instrumenata pro-cene kao u prethodnom istraživanju. Psihijatrijske dijagnoze su bile raspoređene u sledećih pet kategorija: (1) psihotični poremećaji – shizofrenija, shizoafektivni poremećaj, nespecifične funkcionalne psihoze i teška depresija sa psihotičim simptomima; (2) bipolarni afektivni poremećaj i ciklotimija; (3) teška depresija bez psihotične simptomatologije; (4) generalizovani anksiozni poremećaj; (5) fo-bije. Uz to je procenjivan i komorbiditet. Dobijeni rezultati su slični onima koje su dobili i drugi autori, i ukazuju na kauzalnu vezu određenih tipova psihijatrijskih poremećaja i nasilničkog ponašanja. Psihotični poremećaji i bipolarni afektivni poremećaj su pokazali snažnu udruženost sa podacima o fizičkim konfliktima (tu-čama) (rizik se uvećava 3.3 puta) i korišćenjem oružja (rizik uvećan 6.6 puta). Značajnost ostaje i pored kontrole komorbiditeta sa zloupotrebom supstanci, anti-socijalnim poremećajem ličnosti, te sociodemografskim parametrima. Ista veza nije potvrđena kod nepsihotičnih depresija, generalizovanog anksioznog poreme-ćaja i fobija. Takođe je pokazano da, iako ne ključni, društveni činioci kao što je niži obrazovni nivo, bitno utiču na ispitivanu povezanost.

Tabela 8. Rizik od nasilničkog ponašanja kod muške psihijatrijske i prestupnič-ke populacije u odnosu na opštu populaciju muškaraca

Dijagnostička kategorija

Broj ispitanika sa tom Dg u uzorku Relativni rizik

Interval poverenja 95%

Anksiozni poremećaj 14 (1.5%) u uzorku 910 ubica 0.3 0.2-0.5 Distimija 13 (1.4%) u uzorku 910 ubica 0.6 0.3-1.0

Opšta populacija 1

Mentalna retardacija 11 (1.2%) u uzorku 910 ubica 1.2 0.7-2.2

Teška depresija epizoda 27 (3.0%) u uzorku 910 ubica 1.6 1.1-2.4

Shizofrenija bez alkohola (1) 3 pacijenta sa violentnim prestupima u kohorti rođenih - 11,017

3.6 0.9-12.3

Teški mentalni poremećaji 82 u kohorti rođenih – 7,362 4.16 2.23-7.78

Shizofrenija bez alkohola (2) 48 pacijenata u uzorku 1,302 ubica 7.25 4.7-5.4

Shizofrenija psihot. spektar 58 (6%) u uzorku 910 ubica 8.0 6.1-10.4

Homicid recidivisti sa jednim ranijim homicidom 35 između 1,584 ubica 10.4 7.4-14.5 Alkoholizam 357 (39.2%) u uzorku 910 ubica 10.7 9.4-12.2

Antisocijalni poremećaj ličnosti 103 (11.3%) u uzorku 910 ubica 11 9.5-14.4

Shizofrenija sa alkoholom (1) 38 (2.9%) u uzorku 1,302 ubica 17.2 12.4-23.7

Shizofrenija sa alkoholom (2) 4 pacijenta osuđena za violentne prestupe u kohorti rođenih – 11,017

25.2 6.1-97.2

Ubica – prva godina po izlasku iz zatvora 35 između 1,584 ubica 253.8 1,458-441.9

Sudski psihijatrijski pacijent – prva godina po otpustu iz bolnice

Studija praćenja sa srednjim vremenom od 7.8 godina

293.9 119,272.47


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Na Tabeli 8. još jednom dajemo pregled rezultata dobijenih u nekim ovde pomenutim istraživanjima, a tiču se rizika od nasilničkog ponašanja kod određenih psihijatrijskih kategorija u odnosu na opštu populaciju.

Naši rezultati

Kako je procena rizika od nasilničkog ponašanja u ovoj populaciji pacijenata nezadovoljavajuća (uspešnost predviđanja 40-72%), u našem is-traživanju pokušali smo da utvrdimo pomenute činioce rizika kod obolelih od shizofrenije. Istraživanje je urađeno u Institutu za neuropsihijatrijske pore-mećaje “Dr Laza Lazarević”, gde se psihijatrijski zbrinjavaju pacijenti za oblast Beograda i šire okoline. Ispitanici su bili muški pacijenti sa dijagno-zom shizofrenije (ICD-10), stari 18-45 godina, bez težih somatskih bolesti koje bi mogle uticati na rezultate biohemijskih analiza ili neurofiziološke na-laze. U prospektivnom istraživanju odabrano je 138 ispitanika kod kojih su prvo ispitani svi istraživani parametri: sociodemografski (polustrukturisani upitnik – 14 stavki), kliničko-psihopatološki (PANSS skala, Kalgarijska ska-la depresivnosti za shizofrene pacijente – DSS, Skala prehospitalne agresiv-nosti u okviru porodice – SPAUOP, pokušaji samoubistva, upotreba PAS), biohemijski (biogeni amini i njihovi metaboliti u plazmi – NA, DA, A, 5-HT, VMA, HVA, MHPG, 5-HIAA – HPLC tehnikom; testosteron u plazmi – RIA-CT metodom; holesterol u plazmi), i neurološko-neurofiziološki (NES skala, EEG). Nakon toga pacijenti su praćeni svo vreme bolničkog lečenja i po osnovu agresivnosti (Skala ispoljene agresivnosti – OAS) izdvojene su dve grupe: I grupa – shizofreni pacijenti koji su pokazali nasilničko ponaša-nje (nasilni, N = 50), i II grupa – shizofreni pacijenti koji nisu ispoljili agresiv-nost (nenasilni, N = 40). Ostali pacijenti nisu mogli biti svrstani ni u jednu grupu, jer je ispoljena nasilnost bila tek naznačena. Kod pacijenata grupe na-silnih registrovani su značajno lošiji odnosi u primarnoj porodici, veća učes-talost duševnih bolesti u porodici, a tendencija značajnosti nađena je kod pa-rametara “agresivnost u primarnoj porodici” i “lošiji uspeh u školi”. Kao naj-pouzdaniji u predviđanju pokazali su se kliničko-psihopatološki faktori, po-gotovu stavke PANSS skale. Grupa nasilnih imala je izraženiju psihopatolo-giju (klaster opšte psihopatologije i ukupni skor PANSS skale) i veće skoro-ve na pozitivnom klasteru, gde je veza sa sumanutim idejama persekutornog tipa posebno naglašena. Istaknuto mesto među prepoznatim prediktivnim činiocima zauzimaju i nedostatak uvida u svoje stanje, uznemirenost, grandi-oznost, sumnjičavost, hostilnost, nekooperativnost i slabost kontrole impulsa. Hipoteza o koegzistenciji auto- i heteroagresivnosti i ovde je potvrđena u češćim pokušajima samoubistva u predistoriji pacijenata grupe nasilnih. Pre-diktivni značaj komorbiditeta sa poremećajima vezanim za upotrebu PAS prepoznat je u većoj učestalosti pušenja i zloupotrebe drugih PAS u grupi nasilnih, što je tumačeno na više nivoa, od biološkog do socijalnog. Od bio-hemijskih činilaca, prediktivnim značajem izdvojile su se visoke vrednosti 5-HT, NA, i MHPG u plazmi nasilnih ispitanika, kao i negativna korelacija


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nivoa holesterola i fizičke agresivnosti. Kao najmanje ubedljivi pokazali su se neurološko-neurofiziološki činioci, što je verovatno vezano za izostanak ekstremnijih oblika nasilnosti kod nasilnih ispitanika, te dobijene značajne razlike nisu imale potreban kvantitet da bi mogle biti tretirane kao validne. Nalazi idu u prilog stavu da je sklonost nasilnom ponašanju rezultat akumu-lacije činilaca rizika, od kojih nijedan zasebno nije niti neophodan, niti dovo-ljan za predviđanje. I više od toga, videli smo da je preporučljivo sagledavati različite grupe varijabli, jer ne postoji samo jedan put kojim se može objasni-ti nasilničko ponašanje.

Zaključak Na kraju ovog pregleda možemo reći da rezultati većine istraživanja

u sva tri metodološka pristupa jasno pozitivno koreliraju. Uprkos različito osmišljenim istraživanjima, kod svih je dobijen značajno veći rizik od nasil-ničkog ponašanja za populaciju psihijatrijskih pacijenata u odnosu na one koji to nisu. No, opet ne kod svih, nego samo kod određenih dijagnostičkih kategorija, kao što su poremećaji povezani sa upotrebom psihoaktivnih sup-stanci, antisocijalni poremećaj ličnosti, psihotični poremećaji i bipolarni afektivni poremećaj (Tabela 3, 5, 7, 8). Verovatno je da aktivni psihopatološ-ki sadržaji, posebno oni koji se tiču poremećaja opažanja, mišljenja i afekta, imaju veću važnost u proceni rizika nego dijagnoza sama po sebi. Može se pretpostaviti da je ta veza psihijatrijskih oboljenja i violentnog ponašanja ka-uzalnog tipa, ali se moraju uzeti u obzir i specifične okolnosti, kontekst u kojem se međusobno prepliću psihopatologija i činioci sredine. Mora se ipak naglasiti da je obim udruženosti mentalnih oboljenja i nasilničkog ponašanja, ma koliko statistički značajan, ipak skroman u odnosu na činioce kao što su pol, starost, obrazovni nivo ili socioekonomski status [11].

Do sad rečeno neizbežno vodi ka odbacivanju prva dva viđenja ovog problema, gde se, da podsetimo, povezanost ova dva entiteta ili negira, ili smatra lažnom. Potrebna su ipak dalja istraživanja koja će otkloniti mane do-sadašnjih i rezultate time učiniti validnijim. Po preporuci koju daju Link i Stuve [25], dobro epidemiološko istraživanje ovog problema trebalo bi da bude osmišljeno na sledeći način: (1) specifikovati psihijatrijsko oboljenje ili oboljenja od značaja za istraživanje; (2) pratiti reprezentativni uzorak ljudi koji ne boluju od specifikovanog(nih) oboljenja, i one koji su prvi put oboleli od specifikovanog(nih) oboljenja; (3) upoređivati grupe na osnovu nasilnič-kog ponašanja (vrstu, učestalost, intenzitet) koje će se u perspektivi pojavlji-vati. To istraživanje bi dalje trebalo da uključi sveobuhvatni paket pozadin-skih varijabli (individualnih i kontekstualnih) koje mogu uticati na rezultate, i da nađe način da operacionalizuje procenu nasilničkog ponašanja koristeći službene i neslužbene podatke.

U zaključku treba reći i to da je vrlo važno gde ćemo mi psihijatri postaviti ovaj odnos mentalnih bolesti i raznih oblika nasilnog ponašanja. Način na koji mi to sagledamo obojiće stavove zvaničnih struktura društva i,


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još važnije, uticaće na ukupni odnos drugih ljudi prema psihijatrijskim paci-jentima. Ne smemo zaboraviti da većina mentalno obolelih nije nasilna, da su često pre žrtve nego napadači. I kada su nasilni, mnogo je verovatnije da će nasilje biti usmereno prema članovima porodice nego prema ljudima na ulici, na poslu, u školi itd. Na žalost, kako je problem nasilja, videli smo, prisutniji kod njih nego u opštoj populaciji, nužno je prepoznati činioce koji do toga dovode. Time ćemo moći sprečiti ovakva ponašanja, na vreme prepoznati takve pojedince i razlikovati ih od većine drugih koji nisu nasilni.

Psihijat. dan. /2005/37/2/241-256/ Milic M. Are the mentally ill more prone to aggressive behavior?

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Rewiew article

UDK: 616.89-008

ARE THE MENTALLY ILL MORE PRONE TO AGGRESSIVE BEHAVIOR?

Milan Milic

Institute of Neuropsychiatric Diseases

“Dr Laza Lazarevic”, Belgrade

Abstract: Idea of the connection between aggressiveness and mental disorders is pre-sent in the people of different cultures since the beginning of time. Paradoxically, this connec-tion is still not fully accepted in professional circles, although the studies conducted in the past fifteen or so years clearly indicate its credibility. This article presents possible arguments and four current perspectives on understanding this connection. Most of the article contains a re-view of numerous studies conducted on this subject in the past fifteen years, divided according to three basic methodological approaches: studies of prevalence of aggressive behavior among patients who have been or are still treated in psychiatric institutions; studies of prevalence of mental disorders among persons who committed violent criminal acts and were placed in cor-rectional facilities, and studies of prevalence of both mental disorders and violent behavior in the general population sample in a specific community. The results of most studies in each of the approaches almost invariably indicate a significantly higher risk of aggressive behavior in the population of psychiatric patients as compared to the general population, particularly in specific diagnostical categories such as disorders connected with psychoactive substance abuse, psychotic disorders, bipolar affective disorder. In the conclusion, deficiencies of earlier studies are addressed, and a draft proposal is presented for the better quality of future studies on this subject. Finally, the author emphasizes the importance of the psychiatrists’ attitude to this delicate issue, where the study of risk factors and consequent prevention of aggressiveness in this population would prove a far more rational option than unsubstantiated denial of the obvious, which was the case so far, and yet, it would also prove beneficial for the patients themselves, since detecting the aggressive individuals would help differentiate them from the majority of patients, who are not aggressive.

Key words: aggressiveness, criminality, mental disorders, stigma, epidemiology


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Introduction In almost all known cultures in the course of history, aggressiveness

and mental disorders (illnesses) were brought into connection. In one of his discussions, Socrates commented that the number of the mentally ill in Ath-ens had to be very small, since there was very little violence [1]. The public fear of the mentally ill has always been present and well documented [2,3,4]. A phone survey conducted in 1990 covering the entire territory of the USA demonstrated that 80% of participants supported at least one of the following statements: the mentally ill are more prone to acts of violence than other people; it is only natural to be afraid of a mentally ill person; it is important to keep in mind that former patients of mental institutions can be dangerous (Link BG, Columbia University, unpublished manuscript). Violent acts of the mentally ill are more terrifying to us than other forms of violence. To ordi-nary man, they seem mindless, illogical, unpredictable, deadly. Strangely, perhaps ironically, this connection that men have been aware of for centuries, began to be accepted by the mental health professionals only ten to fifteen years ago. There are several reasons for that.

First of all, the insufficiently conclusive studies examining the con-nection between aggressive behavior and mental illnesses. Such studies often have limited validity, due to: non-standardized or unclear definitions of ag-gressive (violent) behavior, mental illness, or both; relying mainly on official data, which causes a specific type of deviation (see the following text); com-parisons with persons who are not mentally ill, with the exclusion or partial inclusion of demographic and situational factors, and study designs that were, as a rule, retrospective in character [1,5,6,7].

Secondly, the attitude of a society towards the mentally ill aggressive persons varies in the course of time, both in a specific culture, and between different cultures. There are diverse ways of coping with the problem, from guarding the mentally ill within their families, to ignoring them, placing them in hospitals, prisons, and even executing them. Until 1960’s, the results of many studies, relying on the official data on the arrest rate due to aggres-sive behavior, indicated that the mentally ill are not more prone to violent acts as compared to general population [8]. At that time, however, most pa-tients remained institutionalized for the most of their lives. The subsequent policy of deinstitutionalization led to a significant increase in this rate. The pressure to downsize mental institutions and release the patients has done ill favor to many of them, leaving them at the street. Several studies in America indicate that the mentally ill individuals, who are also homeless, are highly prevalent among violent offenders [9]. The main cause is believed to be the lack of adequate psychiatric treatment, considering that they do not present for treatment on their own, and have no family or close persons to look after them.

Thirdly, in the past two decades, the use of psychoactive substances such as cocaine, heroin, hallucinogens, sedatives and others, together with alcohol,


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made a grand entrance in the everyday life and led to the general increase in the rate of violence. It has also affected the rate of violence in the mentally ill [10].

Fourthly, the psychiatrists were right to be cautious about further stigmatization of the mentally ill by a story that at the time seemed highly unlikely [8] and linked with potential misuse. Some authors [11] indicate that the mentally ill have often been scapegoats, the easiest persons to blame in the societies with evident violence problems. The presumed danger to others has always been the basic cause of stigmatization of the mentally ill, which influences all aspects of their life.

In the past fifteen years, the corpus of evidence on the credibility of the connection between mental disorders and violent behavior has signifi-cantly increased. This evidence cannot be ignored, nor easily refuted any more. Certain doubts, however, still stand. We will here present a review of epidemiologic articles on the relation between violent behavior and mental disorders, having in mind the lack of information on this issue among the professionals and the general public in our country.

Generally speaking, there are four perspectives among the research-ers on comprehending this relation. The first, with far less supporters than before, denies any connection between mental disorders and violence. The second perspective supports this association, but defines it as false, artificial. The third viewpoint supports causal connection between aggression and mental disorders and tries to identify the exact element of such disorders that causes aggressive acts. Finally, the fourth perspective also supports causal relation, but it connects it to social context.

Review of epidemiological studies Numerous differently designed epidemiological studies have proved

or refuted these ideas, with more or less success. Neither one of the study designs proved to be ideal for this area. On the whole, there are three basic methodological approaches in assessing the potential connection between mental disorders and violent behavior: first, studies of prevalence of violent behavior among patients who have been or are currently treated in psychiat-ric institutions; second, studies of prevalence of mental disorders among convicted and incarcerated felons and; third, studies of prevalence of both mental disorders and violent behavior in the general population sample in a specific community [12].

Studies of the first methodological approach In view of the first approach, different research strategies have been

used: retrospective studies of treated psychiatric patients, monitoring studies of released psychiatric patients, retrospective and prospective studies of psy-chiatric patients born during a specific period of time. For the assessment of violent behavior, the records before, during or after the hospital treatment have been used. Each of these ways of assessment has its flaws that ought to


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be taken into account. If the data are collected prior to hospitalization, an er-ror occurs that often makes generalization of the results impossible – agitated or aggressive behavior is the usual reason for hospitalization. Similarly, re-sults can be inconclusive if assessments are made during hospitalization, and also if aggressive behavior is corrected in the course of treatment. In addi-tion, it can be assumed that severe mental disorders, such as schizophrenia, are treated and hospitalized more frequently, which causes their number in the sample to increase. Finally, assessment after the release is lacking in va-lidity since patients are only released when they are no longer aggressive. On the other hand, the advantage of such studies is that they rely on official data, and are not compromised by subjectivity. In addition, studies of persons born during a specified time period include all registered patients, regardless of the severity of the disease and frequency of hospitalization, and for that reason they are considered to have the highest value in the generalization of the results.

A great majority of studies conducted according to the above metho-dological approach detected the increased risk of violent behavior in specific psychiatric disorders. For example, the studies of Modestin and Amman [13,14], exploring the prevalence of criminal acts linked with violent behav-ior in the population of psychiatric patients at the University Clinic in Bern, Switzerland, point to the three to four times higher risk in male patients suf-fering from schizophrenia and related disorders, as compared to general population. The retrospective study of schizophrenic patients born in Stock-holm between 1920 and 1959 points to the 3.8 times higher risk of violent behavior [15]. The same result was obtained by Wesley et al. [16] in male schizophrenic patients who received their first psychiatric treatment in Lon-don in the period of 1964-1984. The highest increase of the risk of aggressive behavior in schizophrenic patients was discovered by Tiihonen et al. [17]. Monitoring a cohort of persons born in Northern Finland, they found that the probability of convictions for violence-related criminal acts was seven times as high as compared to persons with no psychiatric diagnoses. When assess-ing the risk in psychotic disorders on the whole, the discovered increase was four times for men, and even higher for women [18]. All studies of this type detected a significantly higher risk of aggressive behavior in disorders related to psychoactive substance abuse. In the cohort analysis of 15,117 persons born in Stockholm, Sweden, Hodgins discovered that the relative risk in men with this problem was 15.4, while in female population of users the risk was present in even up to 54.6% [18]. As we can see, the rate is significantly higher than in psychotic disorders. Comparative study by the same author and her associates [19], conducted in Denmark on a large non-selective birth cohort, provided similar results related to the issue. Approximately equal findings were obtained by other researchers as well [13]. Relative risk for the antisocial personality disorder was found to be 7.2 for men and 12.1 for women, i.e. the risk is that much higher as compared with the general popu-lation [19]. A remarkable early paper by Rabkin, from the late 1970’s [20],


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presenting a review of seven studies of the psychiatric patients’ arrest rate, demonstrated that studies conducted before 1965 do not indicate increased arrest rate in psychiatric patients, as opposed to the period of 1965-1979 when every study showed the opposite result. If the later published studies of the same type [21,22,23,24] are combined with Rabkin’s review, the result is the ratio of 3:1 related to the arrest rate – psychiatric patients: general popu-lation [25]. The following Tables (1, 2) present a review of the more signifi-cant studies using this type of approach.

Table 1. Retrospective studies of patients admitted to psychiatric treatment (first five) and retrospective cohort studies (final two)

Authors Location Time period

N Gender Dg group Definition of aggressiveness

Humphreys et al. (1992)

Northwick Park ? 253 m + f Sch (ICD-9)

Life-threatening behavior (estimate of rela-tives)

Modestin & Amman (1995)

Bern 1987 1,265 m + f All disorders (ICD-9)

Official data (police)

Modestin & Amman (1996)

Bern 1985-1987 282 m Sch (RDC) Official data (court)

Volavka et al. (1997)

Check Republic, Denmark, Ireland, Japan, GB, USA, USSR, India, Nigeria

1987 1,017 m Sch (ICD-9)

Physical assaults (estimate of others)

Muntaner et al. (1998)

Baltimore 1983-1989 1,670 m +f Psychoses (DSM-III)

Data obtained from the respondents

Lindquist and Allebeck (1990)

Stockholm 1971-1986 790 m + f Sch (ICD-8)

Official (court)

Wessely et al. (1994)

London 1964-1984 538 m + f Sch (ICD-9) Official (court) and data from the respondents

Table 2. Monitoring studies of treated psychiatric patients (first three) and pro-spective monitoring birth cohort studies (final four)

Authors Location Time period N Gender Dg group Definition of aggresiveness

Swanson et al. (1997)

North Carolina 1986-1991 169 m + f Severe mental disorders.a

Official (hospi-tal, court) and respondents

Steadman et al. (1993, 1998)

Pittsburgh, Cansas City Worchester

1992-1995 1,136 m + f Selected mental disordersb

Data obtained fom the respon-dents

Schwartz et al. (1998)

North Carolina

? 331 m + f Severe mental disordersa

Official (court, police) and respondents

Ortmn (1981) Copenhagen 1953-1978 11,540 m All disorders

Official data (court)

Hodgins (1992) Stockholm 1953-1983 15,117 m + f All disorders

Official (court)

Hodgins et al. (1996)

Denmark 1944-1947 358,180 m + f All disorders

Official (court)

Tiihonen et al. (1997)

North Finland 1966-1992 12,058 m + f All disorders

Official (court)

a Schizophrenia, paranoid psychoses, affective psychoses b Schizophrenic spectrum, affective spectrum, paranoid psychoses, substance abuse


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Table 3. shows results obtained in some of the above studies.

Table 3. Relative risk of violent behavior in mental patients (as compared to general population, where the assumed risk is 1.0)

Authors Severe mental disorders

Organic disor-ders

Sch Affective disisorders

Anxiety disisor-ders

Disorders related to substance abuse

Antisocial perersonal-ity disorder

Modestin & Amman, (1995)

m – 3.1 m – 8.8 m – 6.5

Modestin & Amman, (1996)

m – 3.9

Lindquist & Allebeck, (1990)

m – 3.9

Hodgins, (1992) m – 4.2 f – 27.4

m – 15.4 f – 54.6

Hodgins et al., (1996)

m – 4.5 f – 8.7

m – 2.6 m – 8.7 f – 15.1

m – 7.2 f – 12.1

Tiihonen et al., (1997)

m – 5.0 m – 7.2 10.4

Swanson et al., (1992)

4.1 1.7 1.2

Stueve & Link, (1997)

3.6a /10.1b

3.3a /6.6b 1.4a /1.5b 1.3a /1.2b

a Risk of physical assault; b Risk of using weapons

Studies of the second methodological approach The second methodological approach is represented by two types of stud-

ies: the studies conducted on convicted murderers and diagnostical studies of the representative sample. The studies established on these grounds, as well as a part of studies of the previous approach which analyze the arrest rate of psychiatric patients, have a common weakness: the unsolved dilemma whether the psychiatric patients are arrested more or less frequently. The second problem, affecting only this type of studies, refers to the fact that the evaluation does not include felons-psychiatric patients who were ordered compulsory treatment instead of prison sentence. Both rulings mostly depend on the country and its legisla-tion [26,27]. The third weakness of this type of approach is that it does not include minor aggressive attacks, which are not a sufficient reason for placement in a correctional facility. The advantage of this type of studies, similarly to the previous approach, is working with official data.

The first example of studies conducted on convicted murderers is coming from Finland, a country particularly suitable for this type of research, for two rea-sons. The first one is a high percentage of solved murders – up to 97%, and the second is that every criminal is obliged to undergo a detailed psychiatric evalua-tion. In several published articles, the authors from Finland, primarily Mark Er-onen, discovered that the risk of commiting murder is eight times higher in men suffering from schizophrenia as compared to the normal population, ten times higher in alcoholics, and even more than eleven times higher in antisocial perso-


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nality disorder, while affective and anxiety disorders do not cause the relative risk to increase [28,29,30]. The following three studies, two from Scandinavia and one from Canada, also indicate that among violent offenders there is a large number of persons with severe mental disorders. Gottlieb et al. [31], in their study of murder-ers in Copenhagen in the period of 1959 and 1983, found that 20% of men and 44% of women were diagnosed as psychotic. Among them, 41% of men and 13% of women suffered from a substance abuse related disorder. The results of this re-search showed that in psychotic persons, the risk of committing murder increases six times for men and even sixteen times for women. The following study con-ducted by Lindquist [32] in Sweden, on the overall population of persons who have committed murder in the period of 1970-1981, discovered that the percent-age of psychotic criminals was 53%, and that 38% of disorders were related to psychoactive substance abuse. Finally, the Canadian study conducted on the repre-sentative sample of male homicidal criminals, convicts of the Quebec prison, points to a significantly higher frequency (35%) of severe mental disorders (psy-choses and severe affective disorders) as compared to other offenders imprisoned in the same facility. In the group of homicidal criminals, 83% had a history of al-cohol and 63% of drug addiction. The studies of homicidal recidivist, in the same context, were also highly significant. A Swedish study conducted on the sample of twenty-one repeat killers, found that they were also involved in other types of vio-lent behavior, and that the majority fall into the diagnostic group of personality disorders. Many of them were also alcohol and drug addicts, and 10% was suffer-ing from schizophrenia [33]. Tiihonen and Hakola [34] studied 13 repeat killers, who committed their last crime in the last three years and were imprisoned or placed in a high-security psychiatric institution since then. Mental disorders were diagnosed in all subjects, severe alcoholism combined with personality disorder in eleven of them, and schizophrenic disorder in the remaining two. Table 4. Same studies of homicidal offenders

Authors Location Time period N Gender Diagnostic criterion

Lindquist, (1986) North Sweden 1970-1981 64 m + f ? Gottlieb et al., (1987) Copenhagen 1959-1983 263 m + f ICD-8 Cote & Hodgins, (1992) Quebec 1988 87 m DSM-III Eronen et al., (1996) a, b Finland 1984-1991 693 m + f DSM-III-R

Table 5. Risk of homicidal behavior among male psychiatric patients as com-pared with general male population

Diagnosis Rate in 100 Relative risk 95% Recidive interval Anxiety disorder 1.5 0.3 0.2-0.5 Dysthymia 1.4 0.6 0.3-1.1 Mental retardation 1.2 1.2 0.9-2.2 Severe depressive episode 3.0 1.6 1.1-2.4 Sch without alcoholism 3.7 7.2 5.4-9.7 Sch psychotic spectrum 6.4 8.0 6.1-10.4 Alcoholism 39.2 10.7 9.4-12.2 Antisocial personality disorders 11.3 11.7 9.5-14.4 Alcoholism and previous homicide 13.3 8.9-20.0 Sch with alcoholism 2.9 17.2 12.4-23.7 Sch and previous homicide 25.8 9.6-69.6


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A major deficiency of the studies of the representative sample of general population of prison inmates, i.e. of prevalence of mental disorders in this popu-lation, is that they do not differentiate between violent and non-violent offenses. In spite of this limitation, however, they can help us obtain a general image of the association between mental illnesses and violent behavior. An exceptionally increased rate of alcoholism, substance abuse and antisocial personality disorder was detected in the prison population, especially in female inmates, as compared to general population. The comorbidity of all three disorders is frequent as well [35]. The increased rate of more severe mental disorders, such as schizophrenia or severe affective disorders, as compared to the general population, is reported in a number of published researches conducted on prisoners of both sexes [36, 37,38]. Such serious epidemiological analyses have not been carried out for the territory of our country. We can say that, according to the information available to us, there were practically no significant studies in the last twenty to thirty years, not only considering this one, but also other approaches to this issue.

Table 6. Diagnostical studies of the representative sample of convicted offenders (prison inmates)

Authors Location Time period N Gender Diagnostical criteria

Taylor, (1985) London, GB ? 203 m Hyde & Seiter, (1987) Ohio, USA ? 509 m+f DSM- Neighbors et al., (1987) Michigen, USA 1986 1,070 m+f DSM-III-R Danielet al., (1998) Missouri, USA ? 100 f DSM-III Hodgins & Cote, (1990) Quebec, Canada 1988 495 m DSM-III Teplin, (1990) Cook County, USA 1983-1984 728 m DSM-III Hurley & Dune, (1991) Brisbane, Australia 1989 92 f DSM-III-R Teplin et al., (1996) Cook County, USA 1991-1993 1,272 f DSM-III-R Jordan et al., (1996) North Carolina, USA 1991-1992 805 f DSM-III-R

Table 7. Lifetime prevalence of psychiatric disorders in convicted offenders (prison inmates) without the aggressiveness-based selection of respondents

Diagnosis Neigbors, (1987)

m+f

Hyde & Seiter

(1987) m+f

Teplin (1993)

m

Cote & Hodgins

(1990) m

Hurley & Dune

(1991) f

Daniel (1991)

f

Teplin (1996)

f

Jordan (1996)

f

Schizophrenia 2.8 1.5 3.7 6.5 7 2.4 Severe depression 11.3 12.7 5.7 14.8 19 16.9 13.0 Dysthymia 6.4 3.0 9.6 7.1 Bipolar affective disisorders

0.5 0.9 3.4

Manic episode 1.1 2.5 2 2.6 Agoraphobia 12.0 6 Panic disorders 1.6 0.9 2 1.6 5.8 General anxiety disorders

22.0 2.5 2.7

Obssesive com-pulsive disorders

5.6 6

Antisocial per-sonality disorders

50.1 61.5 29 13.8 11.9

Alcoholism 46.5 28.6 66.9 Together 36 32.3 38.6 Substance abuse 28.7 48.9 with 55.4 26 63.6 44.2


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The studies of the third methodological approach The final, third methodological approach to the research of this asso-

ciation refers to the studies in a selected community (municipality, town, re-gion). The instruments used for assessment are mostly questionnaires filled in by the subjects themselves and sometimes combined with the official data on the arrests due to aggressive outbursts. These types of studies have several advantages over the previous ones. First of all, they eliminate the issue of the so-called “criminalization” of psychiatric patients, i.e. disproportionate refer-ral to the judicial system as compared to the general population. The second advantage, similarly, refers to the so-called “medicalization” of aggressive-ness, i.e. to the occasionally inadequate referral of aggressive individuals to treatment, which increases the rate of aggressive individuals among psychiat-ric patients. Both advantages are achieved by means of unofficial data on violent behavior, obtained from the respondents themselves. The third advan-tage relates to the fact that all respondents come from the same environment, so it cannot be objected that in different environments aggressive behavior is present to a different extent. The limitations of this approach are the subjec-tivity of the information obtained and, in certain studies, exclusion of indi-viduals placed in institutions (prisons or hospitals) due to severe illnesses or offenses.

So far, three significant studies with this approach have been pub-lished. The first study we will address here was conducted with the use of data obtained in a wider American epidemiologic study (Epidemiologic Catchment Area Study), which included 20,000 respondents in five rgions in America, with the aim to establish the number of untreated psychiatric disor-ders. Swanson et al. [39] processed the respondents from three cities: Balti-more, Durham and Los Angeles. They evaluated the data obtained from the respondents themselves, who were asked to declare if they had done some-thing of the following in the previous year: hit their spouse or partner, hit the child so hard it bruised or had to see a doctor, fought with someone other than their spouse or partner, used weapons in a fight or resorted to physical violence while intoxicated. Persons with mental disorder were, generally speaking, more frequently involved in the above aggressive behavior. In the respondents diagnosed with schizophrenia, the risk is over four times higher (4.1), and the highest risk of aggressive behavior is detected in persons suf-fering from disorders related to psychoactive substance abuse, according to this study, ten times higher than in the general population. Fig. 1. shows the presumed probability of aggressive behavior according to gender and psychi-atric diagnoses obtained by the method of logistic regression.


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Fig. 1.

0

5

10

15

20

25

Probality

Sine morba

Anxiet Affective disorders Schizophrenia Substance

abuse Substance abuse and mental disorders orders

Women

Men

The second study, conducted by Link et al. [5] made a comparison between the psychiatric patients and other residents of Washington Heights, a part of New York with ethnically and socio-economically highly heteroge-nous population, based on a number of official and unofficial information. The former were obtained from the state of New York police records, and the latter from the statements obtained from the respondents themselves. In the course of forming the sample, the population of psychiatric patients was di-vided into three groups: those who had first contact with psychiatry in the year preceding the interview, those who were treated earlier, including the year preceding the interview, and, finally, those who were treated earlier, but not in the previous year. By the comparison with the psychiatrically unbur-dened part of the population, a significantly higher arrest rate due to aggres-sive behavior was detected in the psychiatric patients group, both according to official records, and according to the information provided by the respon-dents, as well as a higher rate of physical assaults on other people, fights, use of weapons, severe injuries to others. Time coordinates were either “so far in my life”, or “in the past five years”. The differences remained even with the strict control of sociodemographic factors. The most compelling correlation with aggressive behavior in psychiatric patients was observed in psychotic symptomatology. This result, in the authors’ opinion, supports the credibility of association between aggressive behavior and mental illnesses.

In the third study [40] the authors attempted to provide answers to the questions that were either insufficiently considered, or omitted from the previous two studies. One of the questions is whether the majority of mental illness has positive correlation with aggressive behavior, or this behavior is limited to specific complexes of symptoms or specific disorders. The follow-ing question refers to the possibility that for the most part, this association can be attributed to specific contextual factors, e.g. whether interpersonal aggressiveness is a common way of resolving conflicts in a particular com-munity or not. The final dilemma refers to the assumption that aggressive behavior in the mentally ill can be fully explained by the comorbidity with psychoactive substance abuse and antisocial personality disorder. In Israel, a


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study was conducted on 2,741 respondents, 24-33 years of age, with the use of the same assessment instruments as in the previous study. The psychiatric diagnoses were divided in the following five categories: (1) psychotic disorders – schizophrenia, schizo-affective disorder, non-specific functional psychoses and ma-jor depression with psychotic symptoms; (2) bipolar affective disorder and cyclo-thymia; (3) major depression without psychotic symptomatology; (4) generalized anxiety disorder; (5) phobias. Comorbidity was assessed as well. The results were similar to those obtained by the other authors, indicating the causative association between specific types of psychiatric disorders and aggressive behavior. Psychotic disorders and bipolar affective disorder showed a considerable co-occurrence with the data on physical conflicts (fights) (the risk is 3.3 times higher) and the use of weapons (the 6.6 times higher risk). The significance remains even after controlling for comorbidity with substance abuse, antisocial personality disorder, and sociode-mographic parameters. The correlation, however, was not confirmed in non-psychotic depressions, generalized anxiety disorder and phobias. It was also demon-strated that certain social factors, such as lower educational level, have significant influence on the explored association.

Table 8 presents an additional review of results obtained in some of the above studies, related to the risk of aggressive behavior in specific psychiatric cate-gories as compared to the general population. Table 8. Risk of aggressive behavior in male psychiatric and criminal popu-lation as compared to the general male population

Diagnostical category No. of respondents with this Dg in the sample Relative risk

Recidive interval 95%

Anxiety disorder 14 (1.5%) in the sample of 910 murderers 0.3 0.2-0.5 Dysthymia 13 (1.4%) in the sample of 910 murderers 0.6 0.3-1.0 General population 1 Mental retardation 11 (1.2%) in the sample of 910 murderers 1.2 0.7-2.2 Severe depressive episode 27 (3.0%) in the sample of 910 murderers 1.6 1.1-2.4 Sch without alcohol (1) 3 birth cohort patients

with violent crimes – 11,017 3.6 0.9-12.3

Severe mental disorders 82 in birth cohort – 7,362 4.16 2.23-7.78 Sch without alcohol (2) 48 patients in the sample of 1,302 murderers 7.25 4.7-5.4 Sch psychotic spectrum 58 (6%) in the sample of 910 murderers 8.0 6.1-10.4 Homic recidivists with a prior homicide

35 out of 1,584 murderers 10.4 7.4-14.5

Alcoholism 357 (39.2%) in the sample of 910 murderers 10.7 9.4-12.2 Antisocial disorder l. 103 (11.3%) in the sample of 910 murderers 11 9.5-14.4 Sch with alcoholic (1) 38 (2.9%) in the sample of 1,302 murderers 17.2 12.4-23.7 Sch with alcoholic (2) 4 patatients convicted for violent crimes in the

birth cohort – 11,017 25.2 6.1-97.2

Murderer – first year after release from prison

35 out of 1,584 murderers 253.8 145.8-441.9

Forenzic psychiatric pa-tient – first year after release from hospital

Monitoring study with the average duration of 7.8 years

293.9 119.2724.7


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Our results Since the prediction of risk of aggressive behavior in this population of patients is insufficient (40-72% of successful predictions), in our study we have tried to establish the above risk factors in persons suffering from schizophrenia. The study was conducted at the “Dr Laza Lazarevic” Institute of Neuropsychiatric Disorders, where psychiatric care is provided for the pa-tients of this profile for the territory of Belgrade and the surrounding area. The respondents were male patients diagnosed with schizophrenia (ICD-10), 18-45 years of age, with no severe somatic illnesses that could influence the results of biochemical analyses of neurophysiological findings. In the pro-spective study, 138 respondents were selected and examined for all the tested parameters: sociodemographic (semi-structured questionnaire – 14 items), clinical-psychopathological (PANSS scale, Calgary Depression scale for schizophrenic patients – DSS, Scale of prehospital aggressiveness within family – SPAUOP, sucide attempts, use of PAS), biochemical (biogenic amines and their metabolites in plasma – NA, DA, A, 5-HT, VMA, HVA, MHPG, 5-HIAA – HPLC technique; testosteron in plasma – RIA-CT method; cholesterol in plasma), and neurological-neurophysiological (NES scale, EEG). The patients were subsequently monitored during the entire course of hospital treatment and based on aggressiveness (Overt Aggression Scale – OAS) two groups were differentiated: group I – schizophrenic pa-tients with manifested aggressive behavior (aggressive, N = 50), and group II– schizophrenic patients with no manifest aggressiveness (non-aggressive, N = 40). The remaining patients could not be assigned to any of the groups, since the aggressiveness they manifested was only minor. Significant deterio-ration of the primary family relations, and higher prevalence of mental ill-nesses in the family were registered in the group of non-aggressive patients, and the tendency of significance was also detected in the parameters “aggres-siveness in the primary family” and “poor school achievement”. Clinical-psychological factors turned out to be the most reliable predictors, particu-larly items of the PANSS scale. The group of aggressive patients had a more manifest psychopatholology (general psychopathology cluster and total score in the PANSS scale) as well as higher scores in the positive cluster, with a particular emphasis on the correlation with delusional persecutory ideas. Lack of insight in one’s own condition, apprehension, grandiosity, suspi-ciousness, hostility, lack of compliance and poor control of impulses are also to be found among the recognized predictive factors. The hypothesis on the coexistence of auto- and hetero aggressiveness is also confirmed here, by more frequent sucide attempts registered in the history of patients in the ag-gressive group. Predictive significance of the comorbidity with disorders re-lated to PAS abuse was recognized in the higher prevalence of smoking and abuse of other PAS in the aggressive group, which was interpreted in several levels, from biological to social. Among biochemical factors, high values of 5-HT, NA and MHPG in the plasma of aggressive respondents, proved to be


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of major predictive significance, as well as the negative correlation of choles-terol level and physical aggressiveness. The least conclusive were neurologi-cal-neurophysiological factors, which were probably connected with the lack of more extreme forms of violence in aggressive respondents, so the obtained significant differences did not have the required quantity to be treated as valid. The findings speak in favor of the opinion that the tendency toward aggressive behavior is a result of accumulated risk factors, and any of the factors individually is neither a necessary, nor a sufficient predictor. What’s more, different groups of variables ought to be taken into consideration, since there is clearly more than one way to explain aggressive behavior.

Conclusion In the end of this review, we can say that the results of a vast major-

ity of studies with all three methodological approaches have clear positive correlations. In spite of their different designs, all studies indicate a signifi-cantly higher risk of aggressive behavior in the population of psychiatric pa-tients as compared to those who are not. However, not in all, but only in spe-cific diagnostic categories, such as disorders related to psychoactive sub-stance abuse, antisocial personality disorder, psychotic disorders, bipolar af-fective disorder (Tab. 3, 5, 7, 8). It is likely that active psychopathological contents, especially related to disorders of perception, thinking and affect, are of more importance for the assessment of risk than the diagnosis on its own. It can be presumed that the connection between psychiatric disorders and violent behavior is causative, but specific circumstances, context in which psychopathology and situational factors are intertwined, also have to be taken into consideration. Still, we have to emphasize that the scope of co-occurence of mental disorders and aggressive behavior, however statistically significant, is still minor as compared to factors such as gender, age, educa-tional level or socio-economical status [11].

What is presented so far, inevitably leads to dismissal of the first two opinions on this issue, where the association between the two entities was either denied or considered false. However, further studies are needed to cor-rect the deficiencies of the previous ones and make the results more valid. As recommended by Link and Stueve [25], a good epidemiological study of this issue should be designed in the following manner: (1) to specify the psychiat-ric illness or illnesses of interest to the study; (2) to monitor the representa-tive sample of persons unaffected by the specified illness(es); (3) to compare the groups on the basis of aggressive behavior (type, frequency, intensity) to occur in the perspective. The study should further include a broad set of background variables (individual and contextual) that could influence the results, and to find the way to operationalize the assessment of aggressive behavior by using official and unofficial data.

In conclusion, it should also be noted that it is of major importance where we, the psychiatrists, will position the association between mental ill-


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nesses and various forms of aggressive behavior. The way we consider this issue will influence the opinion of official structures of the society, and, more importantly, the overall attitude of other people toward psychiatric patients. We must not forget that the majority of the mentally ill are not aggressive, that they are victims more often than attackers. Even when they are aggres-sive, it is much more likely that the aggression would be aimed at their fam-ily members and not people in the street, at work, in school, etc. Unfortu-nately, since the problem of violence, as we have seen, is more present in them than in the general population, it is essential to identify such individuals in time and differentiate them from the majority of non-aggressive patients.

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6. Hodgins S. Mental disorders and crime. London: Sage; 1993. 7. Link BG, Monahan J, Stueve A, Cullen FT. Real in their conse-

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8. Torrey F. Violent behaviour by individuals with serious mental illness. Hosp Community Psychiatry 1994;45:653-62.

9. Martell DA. Homeless mentally disordered offenders and violent crimes. Preliminary research findings. Law Hum Behav 1991;15:333-47.

10. Fagan J. Interactions among drugs, alcohol and violence. Health Aff 1993;12:65-79.

11. Marzuk PM. Violence, crime, and mental illness: how strong a link? Arch Gen Psychiat 1996;53:481-86.

12. Eronen M, Angermeyer MC, Schulze B. The psychiatric epidemi-ology of violent behaviour. Soc Psych Psych Epid 1998;33:13-23.

13. Modestin J, Amman R. Mental disorder and criminal behaviour. Br J Psychiat 1995;166:667-75.

14. Modestin J, Amman R. Mental disorders and criminality: male schizophrenia. Schizophrenia Bull 1996;22:69-82.


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15. Lindquist P, Allebeck P. Schizophrenia and crime. A longitudinal follow-up of 644 schizophrenics in Stockholm. Br J Psychiat 1990;157:345-50.

16. Wessely SC, Castle D, Douglas AJ, Taylor PJ. The criminal ca-reers of incident cases of schizophrenia. Psychol Med 1994;24:483-502.

17. Tiihonen J, Isohanni M, Rassainen P, Koiranen M, Moring J. Spe-cific major mental disorders and criminality: a 26-year prospective study of the 1966 Northern Finland birth cohort. Am J Psychiat 1997;154:840-45.

18. Hodgins S. Mental disorder, intellectual deficiency and crime. Evidence from a birth cohort. Arch Gen Psychiat 1992;49:476-83.

19. Hodgins S, Mednick SA, Brennan PA, Schulsinger F, Engberg M. Mental disorders and crime: evidence from a Danish birth cohort. Arch Gen Psychiat 1996;53:489-96.

20. Rabkin JG. Criminal behaviour of discharged mental patients: a critical appraisal of the research. Psychol Bull 1979;86: 1-27.

21. Harry B, Steadman HJ. Arrest rates of patients treated at a com-munity mental health center. Hosp Community Psychiatry 1988;39:862-6.

22. Holcomb WR, Ahr PR. Arrest rate among young adult psychiatric patients treated in inpatient and outpatient settings. Hosp Commu-nity Psychiatry 1988;39:52-7.

23. Shuerman L, Kobrin S. Exposure of community mental health cli-ents to the criminal justice system: client criminal or patient pris-oner? In: Teplin LA. Mental Health and Criminal Justice. Beverly Hills, CA: Sage Publications; 1984. p. 87-118.

24. Shore D, Filson CR, Rae DS. Violent crime arrest rates of White House case subjects and matched control subjects. Am J Psychiat 1990;147:746-50.

25. Link BG, Stueve A. Evidence bearing on mental illness as a pos-sible cause of violent behaviour. Epidemiol Rev 1995;17(1):172-81.

26. Teplin L. The criminality of the mentally ill: a dangerous miscon-ception. Am J Psychiat 1985; 142:669-76.

27. Hodgins S. Mental disorders and crime: an overview. Psychology, Crime and Law 1995;2:5-17.

28. Eronen M, Hakola P, Tiihonen J. Schizophrenia and homicidal behaviour. Schizophrenia Bull 1996;22:83-9.

29. Eronen M, Hakola P, Tiihonen J. Factors associated with homi-cide recidivism in a 13-year sample of homicide offenders in Finland. Psychiat Serv 1996;47:403-6.

30. Eronen M, Hakola P, Tiihonen J. Mental disorders and homicidal behaviour in Finland. Arch Gen Psychiat 1996;53:497-501.

31. Gottlieb P, Gabrielsen G, Kramp P. Psychotic homicides in Co-penhagen from 1959-1983. Acta Psychiat Scand 1987;76:285-92.


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32. Lindquist P. Criminal homicide in Northern Sweden 1970-1981: Alcohol intoxication, alcohol abuse and mental disease. Int J Law Psychiat 1986;8:19-37.

33. Adler H, Lidberg H. Characteristics of repeat killers in Sweden. Crim Behav Ment Health 1995;5:5-13.

34. Tiihonen J, Hakola P. Psychiatric disorders and homicide recidi-vism. Am J Psychiat 1994;151:436-38.

35. Cote G, Hodgins S. Co-occurring mental disorders among crimi-nal offenders. Bull Am Acad Psychiatry Law 1990;18:271-81.

36. Teplin L. The prevalence of severe mental disorder among male urban detainees: comparison with epidemiologic catchment area program. Am J Public Health 1990;80:663-69.

37. Teplin LA, Abram KM, McClelland GM. Prevalence of psychiat-ric disorders among incarcerated women. Pretrial jail detainees. Arch Gen Psychiat 1996;53:505-12.

38. Jordan BK, Schlenger WE, Fairbank JA, Caddell JM. Prevalence of psychiatric disorders among incarcerated women. Convicted felons entering prison. Arch Gen Psychiat 1996,53:513-19.

39. Swanson JW, Holzer ChE, Ganju VK, Jono RT. Violence and psychiatric disorder in the community: evidence from epidemiol-ogical catchment area surveys. Hosp Community Psychiatry 1990;41:761-70.

40. Stueve A, Link BG. Violence and psychiatric disorders: results from an epidemiological study of young adults in Israel. Psychiat Q 997;68:327-42.

___________________________

Milan MILIĆ, dr sci med, psihijatar, načelnik muškog Odeljenja za akutne psihoze u Institutu za neuropsihijatrijske poremećaje “Dr Laza Lazarević”, Beograd, Srbija i Crna Gora

Milan MILIC, MD, PhD, psychiatrist, Head, Department for Male Acute Psychoses, Institute of Neuropsychiatric Diseases “Dr Laza Lazarevic”, Bel-grade, Serbia and Montenegro

E-mail: [email protected]

Psihijat. dan. /2005/37/2/257-270/ Radojević M. Prenatalne predstave očeva o privrženosti...

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Istraživački rad

UDK: 159.9 : 17.023.32

PRENATALNE PREDSTAVE OČEVA O PRIVRŽENOSTI SU PREDIKTIVNE ZA VEZU OCA I DETETA OD

PETNAEST MESECI: AUSTRALIJSKO ISKUSTVO

Marija Radojević

Služba za zaštitu dece, mladih i porodice, Bolnica Hornzbi i Ku-ring-gaj, Sidnej i Grem Rasel Fakultet bihejvioralnih nauka, Univerzitet Makvari

Apstrakt: Ovo istraživanje izveštava o moći predviđanja Intervjua o privrženosti od-raslih (Adult Attachment Interview) Džordža, Kaplana i Mejnove [12] o privrženosti oca i dete-ta u australijskom uzorku muškaraca koji će prvi put postati očevi (N = 44). Testirana su dva modela: onaj od tri kategorije (siguran, omalovažavajući, previše zaokupljen odrasli; sigurno, izbegavajuće, odbojno dete) i od četiri kategorije (siguran, omalovažavajući, previše zaokup-ljen, neodlučan odrasli; sigurno, izbegavajuće, odbojno, dezorganizovano dete); svaki u svom binarnom (siguran/nesiguran) i potpuno ukrštenom obliku. Oba modela pokazala su značajan uspeh u predviđanju ovog odnosa. Najtačnije predviđanje postignuto je kada su klasifikacije ro-ditelja i dece bile podeljene na suprotnosti sigurno/nesigurno [50.9% smanjenja greške (Percent Reduction in Error – PRE)]. Binarni oblik modela sa tri kategorije imao je 45.1% smanjenja greške. Model unakrsne klasifikacije 4 x 4 imao je 40.4% smanjenja greške, i istov-remeno sačuvao najveću specifičnost, čime se ističe prediktivna korist kategorije neodlučan ro-ditelj.

Ključne reči: privrženost otac-dete, predviđanje, AAI


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Teorija privrženosti, i kasnija istraživanja koja je ona podstakla, re-zultirala je tokom poslednjih dvadeset godina jednom od najboljih metodolo-gija kako za proširenje teorije tako i za razumevanje društvenog i osećajnog razvoja deteta. U oblasti istraživanja privrženosti radovi koje su pokrenuli Majkl Lemb i saradnici [1,2,3,4] bili su značajni jer su pokazali i postojanje odnosa privrženosti oca i deteta i njihovu raznovrsnost. Međutim, i površno ispitivanje tekstova o ovoj temi otkriva da je, još od značajnih Lembovih ra-dova [uz neke izuzetke, 5,6,7] u istraživanjima privrženosti uočljiv stalan manjak usredsređenosti na očeve. Tekuća istraživanja o ulozi očeva u ovom odnosu mnogo su produktivnija s obzirom na širinu paradigme razvojnog i psihoanalitičkog pristupa [8,9,10,11].

Stvaranje Adult Attachment Interview (AAI) (Intervjua o privrženos-ti odraslih) i sistema za obradu rezultata ovog instrumenta pokrenulo je pro-gram istraživanja privrženosti odraslih [12,13]. Od nastanka ovog instrumen-ta jedno od središnjih pitanja bilo je određivanje razvojnih pokazatelja kod roditelja koji doprinose tome da oni budu dobri roditelji i, na taj način, utiču na odnos privrženosti između odraslog i deteta. U tom smislu sve je više do-kaza koji govore u prilog kontinuitetu između načina na koji majka mentalno predstavlja i verbalno izražava sopstveno iskustvo odgajanja i načina na koji ona kasnije postupa sa svojim detetom [6,14,7,15]. Smatra se da je za preno-šenje mehanizma kontinuiteta ključan stepen u kojem je majka prijemčiva za signale deteta da mu je potrebna uteha i sigurnost.

Cilj ovog istraživanja je da ispita do koje mere sigurnost mentalne predstave budućih očeva o privrženosti može da utiče na kasniji kvalitet si-gurne privrženosti oca i deteta u nerizičnom, nekliničkom uzorku. U jednoj nedavnoj metaanalizi prediktivne vrednosti AAI [16] izbor je pao na osam-naest istraživanja o odnosu između AAI klasifikacija i klasifikacija privrže-nosti dece. Od ovih osamnaest istraživanja u samo četiri (uključujući i ovo istraživanje) bili su uključeni i očevi. Relativno zanemarivanje očeva u teku-ćim istraživanjima privrženosti ukazuje na to da u njima i dalje postoji pret-postavka primata dijade majka-dete. Ovo je zbunjujuća pretpostavka, iz ne-koliko razloga. Prvo, i teorija privrženosti i istraživanja u toj oblasti ukazuju na to da će sigurna privrženost oca i deteta verovatno imati zaštitno dejstvo ukoliko je privrženost majke i deteta nesigurna [17,5]. Takođe, ukoliko je privrženost oca i deteta takođe nesigurna, manji je broj mogućnosti za inter-akciju koja će zaštititi dete od osećajne i društvene neprilagođenosti [17,18]. Tako priroda afektivne veze između oca i deteta ima mogućnost da funkcio-niše ili kao zaštitni ili kao činilac ranjivosti u razvoju deteta. Na primer, is-traživanja o uspešnošnosti dece iz razvedenih brakova konzistentno pokazuju lošiji psihosocijalni razvoj kod porodica bez oca i u porodicama u kojima je otac deci skoro nedostupan [19,20].

Drugo, razmere društvenih promena u zapadnim industrijskim druš-tvima, naročito u smislu sve češćeg raspada porodice i izmenjenih uslova rada, predstavljaju značajan izazov za mnoge pretpostavke koje se tiču priro-


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de i organizacije porodičnog života i, naročito, roditeljstva. Ove pretpostav-ke, na primer, obuhvataju prvenstvo dijade majka-dete i sekundarnu ulogu oca kao pružaoca nege, za koga se smatra da ima manji uticaj na razvoj dete-ta. U Australiji je u ovom trenutku zaposleno 53% žena, a njih 48% ima naj-mlađe dete staro deset godina [21]. Ova brojka verovatno ne odražava pravu sliku društva jer se stalno povećava broj majki male dece koje se vraćaju na posao. Osim toga, u junu 1996. godine bilo je 672,000 porodica sa samo jed-nim roditeljem, od čega je u 85% slučajeva taj jedan roditelj bila žena. Tako, uzimajući u obzir razmere i značaj društvenih promena, važno je bolje razu-mevanje prirode privrženosti deteta i oca (za koju se, kao i za privrženost između majke i deteta, pretpostavlja da je promenljiva, kao funkcija prijem-čivosti roditelja za dete). Osim toga, moramo da razumemo prirodu i rane pokazatelje afektivne spone oca sa detetom, naročito zato što se oni ispolja-vaju u razmišljanjima očeva o privrženosti, kao i u njihovom roditeljskom ponašanju.

Instrument AAI napravljen je radi predviđanja kvaliteta privrženosti roditelja i deteta koji se procenjuju u nepoznatoj situaciji [22]. Namera je da se nizom pitanja i testova utvrdi stav odraslog u pogledu privrženosti, naroči-to – kako su ovu privrženost doživeli u detinjstvu. Klasifikacija se više osla-nja na koherentnost iskazanih misli i osećanja nego na njihov vidljivi sadržaj. Intervjui su doslovce zapisani, a primenjena je jedna od četiri glavne klasifi-kacije privrženosti: autonomna (F), odbacujuća (Ds), preterana zaokuplje-nost (E) i neodlučna (U).

Sigurni (autonomni) odrasli pružaju relativno koherentan, konzisten-tan i neodbrambeni izveštaj o svojim iskustvima u vezi sa privrženošću, bez obzira na to da li su ta iskustva bila pozitivna ili negativna. Pošto se relativno ugodno osećaju sa većim delom svojih afektivnih iskustava, smatra se da au-tonomni roditelji imaju više slobode od nesigurnih roditelja da saosećajno reaguju na znake uznemirenosti deteta [23,24]. Tako deca očekuju brzu, ose-ćajnu pažnju roditelja.

Najznačajnija osobina nesigurnih/odbacujućih odraslih je njihov im-plicitan ili eksplicitan odbrambeni stav. Očigledna odbojnost odbacujućih odraslih da priznaju sopstvene potrebe za privrženošću čini ih manje osetlji-vim i prijemčivim na potrebe za privrženošću sopstvene dece [24]. U takvim uslovima dete brzo nauči da odvrati pažnju od sopstvenih potreba za privrže-nošću, i tako izgleda (često prerano) samodovoljno.

Nesigurni/preterano zaokupljeni odrasli izgledaju kao da su još uvek ljuti i preterano usredsređeni na zamišljene mane jednog ili drugog roditelja. Reagujući na potrebu deteta za utehom i/ili privrženošću preterano zaokup-ljeni odrasli će verovatno biti nedosledan; ponekad nametljivo dostupan, po-nekad zanemarujući. Ova strategija odgoja stvara kako naglašeno oprezno tako i prigušeno ponašanje privrženosti kod deteta, verovatno zato što dete nije sigurno kako će negovatelj reagovati.


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Konačno, odrasli klasifikovani kao nesigurni/neodlučni pokazuju znakove nerazrešenih traumatskih iskustava, koja obuhvataju ili gubitak zbog smrti ili neku zloupotrebu od strane figure privrženosti. Tvrdi se da će se ne-odlučni roditelj verovatno nenamerno ponašati prema detetu na načine koji mogu da stvore prolaznu strašljivost i sukobe u detetu [25].

Ipak, treba naglasiti da AAI nije jedini instrument kojim se meri pri-vrženost odraslih čija je teorijska osnova u teoriji privrženosti. Rad Hejzena i Šejvera (1990, 1994) svakako je nadahnuo niz istraživanja o privrženosti od-raslih, zasnovanih na merenju samoprocene [26,27,28]. Iako razmatranje ovog značajnog i paralelnog istraživanja nije predmet ovog članka, o njemu elegantno diskutuju Fini i Noler (1996).

Smatra se da su klasifikacije AAI sistematski povezane sa raznim ob-licima privrženosti kod dece, a utvrđuju se testom nepoznate situacije [22]: siguran (B), izbegavajući (A), odbojan (C) i dezorganizovan/dezorijentisan (D) [29]. Suština je u tome da deca pounutre obrasce ponašanja negovatelja tokom ponavljanih interakcija sa roditeljima. Ova pounutrenja zatim postaju deo predstavnih modela odnosa kod deteta. Ovi, pak, modeli, oblikuju i po-našanje deteta i njegova očekivanja u vezi sa ponašanjem drugih ljudi. Smat-ra se da ispoljavanje dečjih obrazaca privrženosti u ponašanju predstavlja strategije ili za mobilisanje ili za ograničavanje svesti o afektima i saznanji-ma povezanim sa privrženošću. Ukratko, to izgleda ovako:

1. deca koja nisu ambivalenta u traženju bliskosti, interakcije ili kon-takta sa majkom koja ulazi u sobu klasifikovana su kao sigurna (grupa B).

2. deca koja oklevaju ili izbegavaju majku prilikom ponovnog sus-reta i koja pokazuju malo ili nimalo znakova da im je nedostajala dok su bili odvojeni određena su kao nesigurna/izbegavajuća (grupa A).

3. deca koja ispoljavaju ljutnju i ambivalenciju prema majci koja se vraća kući klasifikovana su kao nesigurna/ambivalentna (C). Ona plaču i izgledaju kao da žele kontakt, ali ne mogu da se svr-te i vrate igri.

Oblikujući kategoriju nesiguran/dezorijentisan (D), Mejnova i Solo-mon [29] su uočili da “…deca koja se ne mogu svrstati u okviru sistema A, B, C ne izgledaju kao da... podsećaju jedna na drugu na koherentan, organi-zovan način. Ovoj deci su zajednički naleti ponašanja kojima naizgled nedos-taje vidljivi cilj, namera ili objašnjenje” (str. 122). Naše istraživanje je jedno od malog broja koje, do sada, uključuje i kategoriju nesiguran (D).

Od tri istraživanja [6,7,30] koja su procenjivala privrženost i kod majki i kod očeva, i ispitala slaganje jednih, odnosno, drugih sa privrženošću majke i deteta i oca i deteta, Mejnova i saradnici [6] i Van Ijzendorn i sarad-nici [7] našli su snažniju povezanost između majki i dece nego između očeva i dece. Stil i saradnici [30], koristeći dihotomiju siguran/nesiguran odrasli, našli su da je za sigurnu privrženost deteta sigurnost oca isto toliko prediktiv-


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na koliko i sigurnost majke. Nesigurnost oca, pak, značajno je manje od ne-sigurnosti majke povećavala šanse da će privrženost oca i deteta biti nesigur-na. S obzirom da su ova istraživanja obavljena u različitim zemljama (SAD, Holandija, Engleska), može se smatrati da obezbeđuju ukrštene podatke za različite nacije. Pokazalo se da su ovi podaci povezani sa različitim kultural-nim pristupima u podizanju dece i, shodno tome, sa drugačijim raspodelama kategorija privrženosti otac-dete, uprkos činjenici da su u većini zemalja majke primarni negovatelji [31]. Samo su Stil i saradnici [30] koristili pros-pektivni metod. Dok se moć predviđanja jednog istraživanja smatra najbo-ljim naučnim pristupom, Van Ijzendornova [16] metaanaliza pokazala je da u osamnaest istraživanja upravo nacrt istraživanja (objašnjenje unazad, objaš-njenje trenutnog stanja, predviđanje) ne objašnjava različitosti u rezultatima. Mada su iz teorijskih, iskustvenih i kliničkih razloga značajne, u ovim istra-živanjima nisu korišćene ni kategorija neodlučna privrženost odraslog ni de-zorganizovano/dezorijentisano privrženo dete, koju ovakva privrženost pred-viđa, [32,33], niti se o njima izveštava. Sva tri istraživanja uključivala su ne-klinički uzorak, solidno obrazovanje, srednju klasu, gde je majka bila (tako se smatralo) primarni negovatelj.

Ukratko, s obzirom na mane istraživanja koja su ispitivala odnos iz-među privrženosti oca i privrženosti oca i deteta, zaključci nisu mogući. Ova tri istraživanja su ipak pokrenula neka pitanja. Prvo, da li, tokom prvih osamnaest meseci deteta, u domaćinstvima u kojima je majka primarni nego-vatelj, očeva iskustva privrženosti mogu da budu manje uticajna od razvija-nja odnosa privrženosti oca i deteta. Drugo, da li AAI (nezavisno od prena-talne primene) pouzdano mobiliše i odražava duševno stanje oca u pogledu iskustava bitnih za privrženost. Treće, da li će četvorostruki način sistema klasifikacije poboljšati moć predviđanja povećavanjem specifičnosti klasifi-kacije privrženosti odraslih i dece. Preduzeli smo ovo prospektivno istraživa-nje u Australiji kako bismo ispitali odnos između sigurnosti predstava budu-ćih očeva o privrženosti i sigurnosti oca i deteta od petnaest meseci, koristeći klasifikacioni sistem od četiri kategorije. Predvideli smo, na osnovu teorije privrženosti, da postoji veza između sigurnog ili nesigurnog mentalnog mo-dela privrženosti budućeg oca s jedne strane i sigurne ili nesigurne privrže-nosti petnaestomesečnog deteta ocu.

Metod Prvobitni uzorak sastojao se od 66 parova u poslednjem tromesečju

trudnoće, gde su oba roditelja čekala svoje prvo dete. Četiri para su odustala posle prikupljanja prenatalnih podataka zbog selidbe (tri para) i prekida od-nosa (poslednji par). Njihovi demografski podaci ipak su uzeti u obzir kako se ne bi smanjio uzorak, zbog demografskih razloga. Tako je u ukupnom uzorku bilo 62 para. Detaljan opis uzorka može se videti na drugom mestu [34]. Prosečna starost muškaraca bila je trideset godina (od 22 do 43). Ispita-nici su bili iz srednje klase, i većina je bila solidno obrazovana. 85% muška-


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raca završilo je najmanje srednju školu (jedanaesta i dvanaesta godina u Aus-traliji), dok je 50% imalo neki oblik tercijarnog obrazovanja. Na skali pres-tižnosti posla [36], rangiranoj od 1 do 7, srednja ocena očeva je bila 4.1 (1 = najviše – sudija – 1.2; 7 = najniže – grobar – 6.8). U vreme formiranja uzorka 94% parova bilo je u braku, ostatak je bio u stabilnim zajednicama koje uva-žava običajno pravo. Zbog novčanih teškoća istraživanje predviđanja obu-hvatilo je poduzorak od 44 oca. Obavljena su i uporedna demografska istra-živanja predviđanja poduzorka očeva (N = 44), kao i ostatka uzorka očeva. Nije bilo značajnih razlika među grupama u pogledu starosti, nivoa obrazo-vanja ili radnog statusa. Međutim, četrdeset četvoro budućih očeva u istraži-vanju predviđanja bili su oženjeni/u zajednici sa partnerkom duže od ostalih očeva, 5.83 godine, odnosno, 3.54 godine. (kombinovano t = 2.90, d.f. = 63, p < .002). Poduzorak istraživanja predviđanja činio je 21 dečak i 23 devojčice.

Formiranje uzorka Parovi su izabrani iz dve velike državne klinike u Sidneju, jedne ve-

like privatne klinike i dve privatne organizacije za pripremu za porođaj. Pa-rovima je rečeno da će istraživanje ispitivati proces prelaska na roditeljstvo i da će jedan aspekt istraživanja pokušati da pojasni kako iskustvo roditelja iz njihovog detinjstva može kasnije da utiče na njihovo roditeljstvo.

U ovom longitudinalnom istraživanju bilo je pet stadijuma: prenatal-no ispitivanje i ispitivanje sa 6, 11, 12 i 15 meseci. Prilikom svakog testiranja i otac i majka su, nezavisno jedno od drugog, popunjavali niz instrumenata samoprocene (neki su se ponavljali). U poslednjem tromesečju intervjuisani su odvojeno, u svom domu, korišćenjem AAI [12]. U šestom i jedanaestom mesecu napravljeni su video zapisi majke, oca i deteta, i oca i deteta u igri, kod kuće. Sa dvanaest meseci sva deca su procenjena s majkom u nepoznatoj situaciji, a sa petnaest meseci isto je učinjeno s ocem. Ovde se govori samo o podacima iz prenatalnog AAI očeva i podacima o privrženosti otac-dete (u petnaestom mesecu). Dalje istraživanje nije bilo moguće zbog nedostatka sredstava.

Instrumenti Intervju za ispitivanje privrženosti odraslih (Adult Attachment

Interview, AAI) [12] je polustrukturisani intervju snimljen na audio traku, ko-jim se procenjuje i klasifikuje “stav odraslog o privrženosti” [13]. Instrument je opisan u u uvodu.

Pomoćno osoblje u istraživanju napravilo je anonimne transkripte tonskih zapisa i dalo im nove brojeve kako bi se osiguralo da će kasnije kodi-ranje dece u nepoznatoj situaciji biti nasumično. Sva kodiranja obavio je autor. Pouzdanost za naše AAI kategorije bila je 80% (Kapa =.72, p < .001) na dvadeset nasumično izabranih transkripata, što je predstavljalo 32% od ukupnog uzorka (N = 62). Autor je prošla obuku u primeni AAI kod Meri Mejn, Meri Ejnzvort i Erika Hesea.


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Test nepoznate situacije (Strange Situation Procedure, SS) [22]. Ovaj dvadesetominutni, standardizovani laboratorijski test ima dobro utvrđenu pouzdanost i valjanost. Deca su posmatrana kako reaguju na dva kratka od-vajanja od roditelja i na njihov povratak. Deca su razvrstana u kategorije prema svom ponašanju u nepoznatoj situaciji, uz naročit naglasak na ponaša-nje pri ponovnom susretu.

Pouzdanost je utvrdio nezavisni ispitivač. Dogovoreno je da je za če-tiri primarne podele k = .86 (p < .001). Oba ispitivača prošla su obuku u sko-rovanju nepoznate situacije A, B i C kategorije kod Alena Srufa. Osim toga, autor je ustanovila sa Alenom Srufom interlaboratorijsku pouzdanost za ka-tegorije A, B i C. Oba ispitivača bila su uključena u jednonedeljni program obuke za kodiranje kategorije D kod Mejnove i Hesea [25]. Autor je provela tri nedelje 1993. godine radeći sa Mejnovom i Heseom kako bi se obezbedila pouzdanost kodiranja za kategoriju D.

Rezultati Ovde predstavljeni podaci u skladu su sa hipotezom da modeli privr-

ženosti budućih očeva mogu da pomognu u predviđanju prirode privrženosti deteta ocu petnaest do osamnaest meseci kasnije.

Prospektivni modeli privrženosti očeva kao najava privrženosti dete-

ta ocu sa petnaest meseci Postoji nekoliko merenja povezanosti koja dopuštaju tumačenje sma-

njenja greške u procentima (PRE) prilikom predviđanja zavisne varijable uz poznavanja nezavisne varijable. To je, u stvari, slično pojmu varijanse. Delta PRE statistika [37] predstavlja najpreciznije merenje [38]. Početna hipoteza – da u predviđanju nema smanjenja greške (koeficijent = 0) testirana je u odno-su na suprotnu hipotezu – da smanjenje greške postoji (koeficijent > 0). U ovom istraživanju to znači da poznavanje AAI kategorije budućeg oca sma-njuje grešku u predviđanju kategorije privrženosti u kojoj će biti njegovo de-te iznad bilo kog smanjenja greške u predviđanju koje bi se dobilo da nije bila poznata AAI kategorija budućeg oca. Izneti su i standardni stepeni kon-kordanse.

Napravljena je dihotomija siguran/nesiguran i za unakrsni klasifika-cioni model sa četiri kategorije AAI/SS i za tradicionalni model klasifikacije AAI/SS sa tri kategorije. Tako su obrađene četiri Del PRE analize; u svakoj je primenjen različit nivo specifičnosti predviđanja.

Model unakrsne klasifikacije 4x4 (kategorije privrženosti za odrasle:

D/E/F/U i dete: A/C/B/D) Suština ovog istraživanja je utvrđivanje moći predviđanja potpunog

modela unakrsne 4 x 4 klasifikacije. S obzirom da koristi kategoriju nesigu-ran/neodlučan odrasli kao prediktor stanja deteta kao nesigurnog/dezorga-nizovanog, ovo je najsloženiji model.


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Ćelijske frekvencije, osim ćelija predviđanja i greške, u potpunom modelu 4 x 4 unakrsne tabulacije (40.4 PRE, p < .0001, konkordansa 56.8%) prikazane su u Tabeli 1. Greška u predviđanju kategorije privrženosti kod deteta (od četiri moguće) smanjena je za 40.4% kada je predviđanje pravlje-no na osnovu poznavanja kategorije privrženosti (od četiri) budućeg oca. Će-lije sa sabranim skorom su ćelije predviđanja. Ćelije koje nisu sabrane pred-stavljaju ćelije greške.

Tabela 1. Tabela unakrsne 4 x 4 klasifikacije sigurne privrženosti deteta i oca (N = 44)

Sigurna privrženost deteta A B C D Sigurna privrženost odraslog D 5 1 1 1 8 F 1 11 3 1 16 E 3 1 1 2 7 U 1 3 1 8 13 10 16 6 12 44

Konkordansa između kategorije E kod odraslog i kategorije C kod

deteta bila je veoma niska, 14.3%, što ukazuje da kategorija E kod odraslog (nesiguran/previše zaokupljen) ne predskazuje dobro stanje deteta C (nesi-gurno/odbojno). S druge strane, u skladu s predviđanjem, budući očevi koji su klasifikovani kao nesigurni/neodlučni (U) imali su decu koja su pokaziva-la nesigurnu/dezorganizovanu (D) privrženost očevima.

Greška u predviđanju sigurnosti, odnosno, nesigurnosti dece smanje-na je za 50.9% kada je predviđanje pravljeno na osnovu znanja da li je privr-ženost budućeg oca bila sigurna ili nesigurna (dihotomija od četiri kategori-je). Tabela 2. pokazuje ćelijske frekvencije između prediktivnih i ćelija sa greškom u ovim uslovima (50.9 PRE, p < .0003, konkordansa 77.2%).

Tabela 2. Tabela dihotomne unakrsne klasifikacije sigurne privrženosti očeva i dece (svedena iz četiri kategorije) (N = 44)

Sigurna privrženosti deteta Sigurno Nesigurno

Siguran 11 5 16 Nesiguran 5 23 28

Sigurna privrženost odraslog

16 28 44

Model 3 x 3 unakrsne tabulacije (Odrasli D/E/F i dete A/C/B katego-rije)

Kada je predviđanje pravljeno na osnovu znanja o tome koja je kate-gorija privrženosti dodeljena budućem ocu (od tri moguće), greška u predvi-đanju kategorije u koju će spadati privrženost deteta (od moguće tri) pala je na skromnih 29.7%. Tabela 3. pokazuje ćelije frekvencije između ćelija pre-dviđanja i greške u modelu 3 x 3 unakrsne klasifikacije (29.7 PRE, p < .007, konkordansa 54.5%).


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Tabela 3. Tabela unakrsne 3 x 3 klasifikacije sigurne privrženosti oca i deteta (N = 44)

Sigurna privrženost deteta A B C

D 8 1 3 12 F 1 14 4 19

Sigurna privrženost odraslog E 5 6 2 13 14 21 9 44

Greška u predviđanju sigurnosti deteta smanjena je za 45.1% kada je

predviđanje pravljeno na osnovu poznavanja da li je privrženost oca sigurna ili nesigurna (dihotomija iz tri kategorije). Tabela 4. pokazuje frekvencije između ćelija predviđanja i greške u ovakvim uslovima (45.1 PRE, p < .00014, konkordansa 72.7%).

Tabela 4. Tabela dihotomne unakrsne klasifikacije sigurne privrženosti oca i deteta (izvedena iz tri kaegorije) (N = 44)

Sigurna privrženost deteta Siguran Nesiguran

Sigurna privrženost odraslog Siguran 14 5 19 Nesiguran 7 18 25 21 23 44

Kao i u modelu sa četiri kategorije, stepen konkordanse između kate-

gorija odrasli E i dete C bila je veoma niska – 15.4%. Njen uticaj na smanji-vanje moći predviđanja u modelu 3 x 3 još je veći jer opstaju samo dve mo-guće kategorije za dodeljivanje.

Svi opisani modeli predviđanja pokazali su značajan uspeh u predvi-

đanju. Ova analiza ukazuje da, sve u svemu, poznavanje prirode modela pri-vrženosti budućeg oca pruža dobar prediktivan kriterijum za organizaciju privrženosti njegovog deteta, nekih petnaest do osamnaest meseci kasnije. Međutim, najbolji rezultati predviđanja postignuti su kada su klasifikacije i očeva i dece bile dihotomne – siguran nasuprot nesiguran. Nedostatak ovog pristupa je smanjenje specifičnosti predviđanja. Prihvatljiv kompromis pos-tignut je u modelu unakrsne klasifikacije 4 x 4, sa PRE = 40.4 uz očuvanje najveće moguće specifičnosti. Ovaj model, osim toga, pokazuje korisnost kategorije očeva neodlučan kao ranog pokazatelja buduće dezorganizova-ne/dezorijentisane privrženosti deteta ocu. Ipak, ostaje značajan nivo greške u predviđanju, čak i u najboljem modelu.


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Diskusija Uočena je značajna i umerena do umereno snažna povezanost između

razvojne istorije oca i kvaliteta privrženosti deteta ocu posle petnaest meseci života. Tako, na najnižem nivou analize, čak i pre nego što je dete rođeno, mogli su se razlikovati očevi čija će deca razviti sigurnu nasuprot nesigurnoj privrženosti sa njima tokom prvih petnaest meseci svog života. Čak i na ni-vou analize kategorija-po-kategorija predviđen odnos ostao je značajan, ma-da manje naglašen.

Ovi nalazi u skladu su sa nalazima drugih istraživanja koja su ispiti-vala odnos organizacije privrženosti kod odraslih i kod dece, uz korišćenje AAI. Od tri istraživanja koja su ispitivala odnos otac-dete sa AAI/SS, Mej-nova i saradnici [6] su našli da je povezanost značajna, ali manje snažna od povezanosti majka-dete sa AAI/SS. Međutim, Stil i saradnici [30] nalaze da su i sigurnost i majke i oca na AAI bile jednako prediktivne za sigurnost pri-vrženosti deteta. Van Ijzendorn i saradnici [7] s druge strane, nisu našli da je usklađenost između očeve i dečje privrženosti statistički značajna, mada je usklađenost između majčine i dečje privrženosti bila statistički značajna. Međutim, ovi autori ističu da je post hoc analiza procene privrženosti kod odraslih, nekoliko godina posle merenja dečje privrženosti, mogla da utiče na njihove podatke. Nalazi, uzeti zajedno, ukazuju da način na koji roditelji do-življavaju i verbalno se prisećaju svojih najranijih i trenutnih afektivnih veza direktno utiče na kvalitet odnosa privrženosti između roditelja i deteta, vero-vatno zato što ova shvatanja ili mentalne predstave o privrženosti utiču na ponašanje roditelja prema detetu.

Proporcija sigurnih modela privrženosti (36% za četvorostruku i 43% za trostruku AAI klasifikaciju) uočena kod budućih očeva izgleda nisko za normativan uzorak. Međutim, ovi nalazi spadaju u okvir klasifikacije privr-ženosti kod odraslih kao autonomne, o kojoj izveštavaju drugi istraživači. Na primer, van Ijzendorn i saradnici [7], koristeći sistem trostruke klasifikacije, označili su 48% svog uzorka kao kategoriju autonoman (N = 29). Autor na drugom mestu opširnije razmatra uporedne nalaze [34]. Štaviše, u metaanali-zi van Ijzendorna [16] osamnaest AAI/SS istraživanja nađeno je da podaci iz ovog istraživanja nisu anomalni.

Dodatni kvalitativni podaci koji govore o mogućim stilskim razlika-ma u reakcijama u AAI između očeva i majki mogu da budu korisno sredstvo kojim bi se unapredilo razumevanje mentalnih procesa povezanih sa odno-som oca i deteta. Van Ijzendornova [16] metaanaliza nije našla da su očevi značajno više zastupljeni u odnosu na majke u kategoriji D. Nezvanično, is-pitivači nisu pokazali bilo kakvu razliku u pristupu AAI između budućih oče-va i njihovih trudnih partnerki. Manjak sredstava onemogućio je da se obrade i podaci iz ispitivanja majki na AAI.

Ovo istraživanje važno je iz nekoliko razloga. Prvo, prospektivni, longitudinalni stil istraživanja koji je koristio četvorostruku klasifikaciju pri-vrženosti odraslih i dece uspešno je predvideo kontinuitet u prirodi i kvalitetu


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odnosa otac-dete kroz generacije. Ono stoga pruža snažnu podršku paradigmi privrženosti, zbog valjanosti AAI kao instrumenta, i zbog značaja oca u druš-tvenom i osećajnom razvoju deteta.

Dokazi da očevi nezavisno utiču na odnos privrženosti sa svojom de-com, snažni su [39], s obzirom da nije nađen odnos između relativnog rodi-teljskog angažmana i sigurnosti privrženosti deteta. Nalazi ovog istraživanja podržavaju nalaze Frodija i saradnika [39]. Oni ukazuju da, čak i u doma-ćinstvima u kojima je majka primarni pružalac nege, istorija oca i njegove mentalne predstave o iskustvima privrženosti jednako utiču u određivanju kvaliteta privrženosti između oca i deteta koliko i istorija majke na privrža-nost majka-dete. Stoga možemo da pretpostavimo da su mentalni procesi od-raslih koji su u vezi sa privrženošću i njihovo prenošenje – isto. Naravno, to ostavlja otvoreno pitanje koje su postavili Mejnova i saradnici [6] o postoja-nju u detinjstvu hijerarhijskog rasporeda u organizaciji radnih modela privr-ženosti, koji favorizuje primarnog negovatelja. Sadašnji nalazi ne mogu da daju odgovor na ovo pitanje. Međutim, oni ipak ukazuju na značaj mentalnog stanja oca u vezi sa privrženošću u društvenom i osećajnom razvoju deteta, naročito s obzirom da je u ovom istraživanju otac sekundarni negovatelj. S tim u vezi, ovde opisani pozitivni prediktivni nalazi ukazuju da AAI može pouzdano da mobiliše i odrazi mentalna stanja oca u vezi sa privrženošću, i razlike među njima, podržavajući tako valjanost AAI u uzorku očeva.

Drugi važan aspekt ovog istraživanja jeste u tome što je ono jedno od malog broja istraživanja koja su uključila kategoriju nesiguran/siguran odra-sli u normalan uzorak prediktivnog istraživanja [40,25]. Dodatno je značajno to što je ovo prvo prospektivno istraživanje sa očevima. Ono stoga dozvolja-va procenu doprinosa u predviđanju specifikovanije strukture unakrsne klasi-fikacije. S tim u vezi, a u pogledu privrženosti između oca i deteta, treba reći da je samo 36% odnosa u nepoznatoj situaciji klasifikovano kao sigurno (vi-di Tabelu 1). Logično, dodatak druge kategorije smanjiće brojeve u ostalim kategorijama. Mejnova [41] ukazuje da je uvođenje kategorije dezorganizo-vano dete, uopšte uzev, imalo efekat smanjenja broja dece klasifikovane u siguran odnos privrženosti. Na primer, Mejnova i Solomon [29] izveštavaju da je u istraživanju Mejnove i Vestona [5] (u kojem se ispitivala i privrženost otac-dete) 13 od 19 dece procenjeno kao teško za klasifikaciju, u kasnijem istraživanju sa 152 nepoznate situacije “...bilo identifikovano kao sigurno s roditeljem kada su korišćeni standardni postupci klasifikacije” [25].

U ovom istraživanju uklanjanje kategorije nesiguran/dezorganizovan iz analize za rezultat je imalo da je 48% dece procenjeno da ima siguran od-nos privrženosti sa ocem. Ovaj nalaz je u skladu sa podacima Mejnove i sa-radnika [5] i sa tvrdnjama Mejnove [29]. Mada ove proporcije sigurne privr-ženosti otac-dete mogu da izgledaju male one nisu u neskladu sa metaanali-zom Ijzendorna i Kronenberga [31] kulturno različitih obrazaca privrženosti. Osim toga, obrazac sigurne privrženosti otac-dete pojavio se kao model i u 3 x 3 i u 4 x 4 modelu unakrsne klasifikacije (vidi Tabele 2 i 4).


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S tim u vezi, 27% dece (N = 12) bilo je klasifikovano da pokazuje nesigurnu/dezorganizovanu privrženost očevima. Ovaj nalaz je u skladu sa nalazom Ejnzvortove i saradnika [40] koji imaju sličnu proporciju D dece (33%) u svom neselektivnom uzorku dijada majka-dete. Zanimljivo je da su u našem istraživanju jedino nesigurna/dezorganizovana deca sa alternativ-nom klasifikacijom kao sigurna ona deca podklasifikovana kao B4 (N = 5); grupa čiji je status u klasifikaciji siguran bio doveden u pitanje [42,43].

Neodlučna privrženost oca (koja je u svim slučajevima osim jednog bila rezultat gubitka zbog smrti) nađena je kao umereni pokazatelj da će dete biti nesigurno/dezoranizovano (konkordansa = 61.5%)1. Ovi nalazi mogu se porediti sa nalazima Mejnove i Hesea [25] koji izveštavaju o 60% slaganja u svom odabranom uzorku od 53 dijade majka-dete. Ejnzvortova i Ajhberg [40], s druge strane, izveštavaju o 100% slaganja u njihovom istraživanju sa neselektivnim uzorkom od 45 dijada majka-dete. Međutim, možda je najvaž-nija stvar to da u tri istraživanja (uključujući i naše), roditelji koji ili nisu is-kusili gubitak značajne osobe ili, ako jesu, izgleda da su razrešili taj gubitak, nisu imali decu koja bi u nepoznatoj situaciji bila procenjena kao dezorgani-zovana u odnosu sa njima. Tako izgleda da nedostatak prevladavanja tugo-vanja kod roditelja može da bude veći činilac rizika za nepovoljne razvojne posledice kod deteta nego gubitak sam po sebi. Mejnova i saradnici [6] i Ke-sidi [38] izveštavaju o šestogodišnjacima koji su kao deca bili procenjeni kao nesigurni/dezorganizovani sa roditeljem, i pokazuju kontrolišuće ili kažnja-vajuće ponašanje prema tom roditelju. Osim toga, ova deca su se uključila i u razvojno neprikladne odnose zamene uloga roditelj-dete. Novije teorije o pri-rodi razvoja mentalnog stanja dece klasifikovane kao dezorganizova-na/dezorijentisana u detinjstvu spekulišu da ova deca mogu, kao odrasle osobe, da budu ranjivija na razvoj disocijativnih duševnih poremećaja [44].2 Ako priroda očevog odnosa sa detetom ima potencijal da deluje kao zaštitni ili činilac ranjivosti u razvoju deteta, kao što se predlaže u teoriji privrženosti i istraživanjima koja se bave privrženošću [17,5,18] onda dete sa dezorgani-zovanom privrženošću neodlučnom ocu može da bude naročito ranjivo.

Dok su se u ovom istraživanju mogli razlikovati i pre rođenja deteta očevi dece koja će razviti sigurnu, nesigurnu/izbegavajuću ili nesigur-nu/dezorganizovanu pruvrženost, to nije bio slučaj sa očevima čija su deca razvila nesigurnu/odbojnu privrženost. Prospektivno istraživanje Fonagija i saradnika [15] niskorizičnih dijada majka-dete iz srednje klase, uz korišćenje 3 x 3 modela unakrsne kilasifikacije, takođe je pokazalo da je majčin status nesigurna/previše zaokupljena slabo predskazivao nesigurnu/odbojnu privr-ženost deteta. S druge strane, u visoko rizičnom uzorku Vord, Botjanski,

1 Od 62 oca, 51 (83%) je, tokom svog detinjstva, mladosti ili kao mlađi odrasli, iskusilo gubitak zbog smrti roditelja ili druge osećajno važne osobe. Mada su drugi, više simbolični gubici (poput onih koji se pojavljuju u situacijama razvoda) smatrani važnim aspektima istorije privrženosti pojedinca, nije se smatralo da su određujući za status neodlučan.

2 Ova ideja dobija izvesnu podršku iz iskustva i nedavnih [44] i tekućih istraživanja koja ispituju odnos između kategorije neodlučan i psihopatologije disocijativnih poremećaja [33,44].


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Planket i Karlson [46] nalaze dobru predvidljivost u kategoriji nesigu-ran/previše zaokupljen odrasli, kao i Mejnova [lično saopštenje, 41] u svom uzorku niskog rizika. Mejnova i Solomon [33] su uočili da dečji obrazac ne-siguran/odbojan može da bude manje “dobro organizovan” u poređenju sa drugim obrascima privrženosti. To može da bude slučaj i sa mentalnim sta-njem nesiguran/previše zaokupljen odrasli. Uočite da je u 4 x 4 modelu una-krsne klasifikacije previše zaokupljen roditelj bio dobar pokazatelj opšte ne-sigurne privrženosti deteta (konkordansa = 85.7% – A, D, C). Jasno je da buduća istraživanja treba da razjasne moć predviđanja ove kategorije. Ovo istraživanje je pokazalo dobru predvidljivost modela četvorostruke unakrsne klasifikacije (40.4 PRE) u poređenju sa skromnijim rezultatima modela tros-truke unakrsne klasifikacije (29.7 PRE). Snaga četvorostrukog modela poči-va na dobroj prediktivnoj moći kategorija siguran, nesiguran/omalovažava-jući i nesiguran/neodlučan s jedne strane i loše prediktivne moći kategorije nesiguran/previše zaokupljen, s druge strane. Do sada se kategorija neodlu-čan upotrebljavala u malom broju istraživanja. Međutim, sadašnji nalazi ukazuju na njen značaj u budućim istraživanjima odnosa između AAI i SS klasifikacija, naročito u svetlu sve više dokaza koji su i sve snažniji, a izgle-da da povezuju neodlučnu privrženost odraslog i dezorganizovanu/dezo-rijentisanu privrženost deteta sa lošim prilagođavanjem u odnosima.

Treće, ovo istraživanje je značajno jer je sprovedeno u Australiji, u kojoj do sada nije bilo istraživanja sa korišćenjem Intervjua o privrženosti odraslih. Uspeh predviđanja u australijskom uzorku očeva ukazuje da je AAI kulturno valjan instrument za upotrebu u Australiji, barem u uzorku muška-raca srednje klase. On potvrđuje univerzalnost stanja duha u pogledu privr-ženosti koju AAI procenjuje.

Zbog malog broja ispitivanja očeva sa AAI i zbog nužnih ograničenja u nacrtu istraživanja, nalazi ovog istraživanja zahtevaju pažljivo tumačenje. U slučaju neskladnih odnosa otac-dete, ponovljeno merenje analize o poda-cima iz samoizveštaja ukazalo je na trend da su sigurni očevi sa nesigureno privrženom decom iskusili veće intra- i interpersonalne teškoće tokom pre-laska u roditeljstvo u odnosu na nesigurne očeve čija su deca bila sigurno privržena sa petnaest meseci. Buduća istraživanja sa većom populacijom, mnogo raznolikijom u pogledu kulturnih i društveno-ekonomskih činilaca, mogu bolje da ispitaju snažnu ulogu psihološkog stresa, kao i psihološke ot-pornosti. Osim toga, nije poznat stepen do koga je greška u predviđanju mo-gla biti rezultat grešaka u postupku ili obradi podataka, ili pak izmenjenih predstava očeva o privrženosti tokom prelaska u očinstvo. Ova kontingencija mogla bi se u budućim prospektivnim istraživanjima bolje obraditi uz upot-rebu pretesta i retesta.

Bez obzira na ova ograničenja, ovo istraživanje pruža značajne pros-pektivne podatke koji podržavaju paradigmu privrženosti, pokazujući da pos-toje zakonomerni odnosi između načina na koji očevi zamišljaju svoju sops-tvenu razvojnu istoriju i kako podižu sopstveno dete. Osim toga, pokazalo se


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da je AAI sposoban da prenatalno razlikuje one očeve čija će deca kasnije postati sigurno ili nesigurno privržena. Naročito je važno da upotreba kate-gorija neodlučan odrasli/dezorganizovano dete u ovom istraživanju pruža prvi dokaz prospektivne iskustvene veze ovo dvoje u niskorizičnom uzorku roditelja. Na kraju, usredsređivanje na dijadu otac-dete donelo je nove zna-čajne uvide u to kako očevo shvatanje sopstvenog razvoja oblikuje prirodu ovog za njega važnog odnosa.

Izjave zahvalnosti Autor se zahvaljuje Meri Mejn na njenim promišljenim komentarima

na ranije verzije ovog članka, Dajeni Benoa i Džonu Lordu na proveri pouz-danosti AAI, odnosno, dečjeg SSP, i Alenu Tejloru za statističku obradu.

Psihijat. dan. /2005/37/2/271-287/ Radojevic M. Prenatal paternal representations of attachment predict infant-father

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Research article

UDK: 159.9 : 17.023.32

PRENATAL PATERNAL REPRESENTATIONS OF ATTACHMENT PREDICT OF INFANT-FATHER

ATTACHMENT AT 15 MONTHS: AN AUSTRALIAN STUDY

Marija Radojevic

Child, Adolescent and Family Service, Hornsby and Ku-ring-gai Hospital,

Sydney and Graeme Russell School of Behavioral Sciences, Macquarie University

Abstract: This study reports the power of the George, Kaplan and Main [12] Adult Attachment Interview (AAI) to predict infant-father attachment in an Australian sample of first-time prospective fathers (N=44). Both the three category (Secure, Dismissing, Preoccupied adult; Secure, Avoidant, Resistant infant) and the four category (Secure, Dismissing, Preoccu-pied, Unresolved adult; Secure, Avoidant, Resistant, Disorganized infant) models were tested; each in its binary (Secure/Insecure) and in its full cross-tabulation form. All models demon-strated significant predictive success. Strongest prediction was achieved when paternal and in-fant classifications were dichotomized to Secure vs. Insecure (50.9 Percent Reduction in Error – PRE). The binary form of the three category model yielded a 45.1 PRE. The 4x4 cross-classification model yielded a 40.4 PRE and preserved maximum specificity, thereby highlight-ing the predictive usefulness of the paternal Unresolved category.

Key words: infant-father attachment, prediction, AAI


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Attachment theory, and the subsequent research activity it has gener-ated has, over the last 20 years, has resulted in one of the most robust meth-odologies for both theory expansion and for the understanding of child so-cial-emotional development. Within the attachment research domain, the body of work generated by Michael Lamb and his associates [1,2,3,4] has been of importance because it has demonstrated both the existence and the variability of the father-infant attachment relationship. However, a cursory inspection of the attachment literature reveals that, since Lamb's important corpus of work, a continuing sustained focus on fathers in attachment re-search has been notable by its absence in published work [with some excep-tions 5,6,7]. However, ongoing research into the father's role has been more productive within broader developmental and psychoanalytic paradigms [8, 9,10,11].

The development of the Adult Attachment Interview (AAI), and its coding system, launched the adult attachment research program [12,13]. Since its inception, one of the central questions has been to determine devel-opmental antecedents in the parent which contribute to caregiving and hence, to variable infant attachment outcomes. Within this framework, there is ac-cumulating evidence for continuity between the way a mother mentally represents and verbally constructs her own experience of being reared on the one hand, and the way that she subsequently treats her child on the other [6, 14,7,15]. The transmission mechanism for continuity is considered to be the degree to which the infant's mother is responsive to its signals for comfort and security.

The aim of this study is to examine the extent to which the security of expectant fathers' mental representations of attachment may influence the subsequent quality of infant-father attachment security in a low-risk, non-clinical sample. In a recent meta-analysis of the predictive validity of the AAI [16] the selection procedure yielded 18 studies on the relation between AAI classifications and infant attachment classifications. Of these 18 studies, only four (including the present study) involved fathers. The relative neglect of fathers in ongoing attachment research suggests that an assumption of the primacy of the mother-infant dyad continues to underlie attachment research endeavours. This is puzzling for several reasons. First, both theory and re-search within the attachment paradigm suggest that a secure infant-father at-tachment is likely to provide a buffering effect should the infant-mother at-tachment be insecure [17,5]. Alternately, if the infant-father attachment is also insecure, then fewer interactional opportunities exist to buffer the child against social-emotional maladaptation [7,18]. Thus, the nature of the affec-tional tie between father and child has the potential to function as either a protective or a vulnerability factor in the child’s development. For example, studies of child outcome in divorced families consistently demonstrate poorer psychosocial outcomes in father absent families and in families in which children have minimal access to their father [19,20].


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Second, the degree of social change in Western industrial countries, particularly with respect to increasing family breakdown and changing work practices, poses significant challenges to many assumptions attending the nature and conduct of family life and in particular, of parenting. These as-sumptions include, for example, the primacy of the mother-child dyad and the secondary caretaker status of the father who is presumed to exert a re-duced impact on infant development. Currently in Australia, 53% of women are in the paid work force and of these women, 48% had a youngest child of ten years of age [21]. This figure likely under-represents the current situation because of the continuing increase in the return of mothers of young children to the paid work force. Further, in June 1996 there were 672,000 one parent families and of these, 85% were headed by a woman. Thus, given the scale and significance of social change it is important to understand better the na-ture of the child’s attachment relationship with his or her father (which, like infant-mother attachment, is presumed to vary as a function of paternal re-sponsiveness to his infant). Additionally, we need to understand the nature and antecedents of the father’s affectional tie to his child, particularly as these are expressed in paternal reflections about attachment and in paternal behavior.

The AAI was developed to predict the quality of infant-parent at-tachment relationships as assessed in the Strange Situation [22]. Via a series of questions and probes it is designed to assess an adult’s state of mind with respect to attachment relationships, particularly as these relationships were experienced in childhood. Classification relies more on the coherence of ex-pressed thoughts and feelings than it does on actual content. Interviews are transcribed verbatim and one of the four major classifications is assigned: Autonomous (F), Dismissing of Attachment (Ds), Preoccupied by Attachment (E) and Unresolved with respect to Attachment (U).

Secure (Autonomous) adults provide relatively coherent, consistent and non-defensive accounts of their attachment relevant experience, irrespec-tive of whether it was actually positive or negative. In being relatively com-fortable with the full range of their own affective experience, Autonomous parents are thought to be freer than Insecure parents to respond empathically to the child’s distress signals [23,24]. Hence the child's expectation is of prompt affectionate attention.

The most outstanding characteristic of Insecure/Dismissing adults is the defensiveness implicit and explicit in their discourse. The seeming reluc-tance to acknowledge their own attachment needs may make the Dismissing adult less sensitive and responsive to the affectional needs of the child [24]. Under these conditions the child learns quickly to deflect attention from its own attachment needs and thus appears (often precociously) self sufficient.

Insecure/Preoccupied adults seem to still be angry and overinvolved with the perceived shortcomings of one or other parent. In response to the infant's attachment bids for comfort and/or affection, the Preoccupied adult is


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likely to be inconsistent; sometimes intrusively available, at other times ne-glectful. This caregiving strategy creates both hypervigilance as well as at-tenuated attachment behavior in the child, presumably because the child is not sure how the caregiver will respond.

Finally, adults classified as Insecure/Unresolved show signs of unre-solved experiences of trauma, involving either loss through death or else abuse suffered at the hands of an attachment figure. It is postulated that the Unresolved adult is likely to inadvertently behave towards the infant in ways which may engender transient fearfulness and conflict in the child [25].

Nevertheless, it should be noted that the AAI is not the only measure of adult attachment whose theoretical basis lies in Attachment Theory. In-deed, the work of Hazan and Shaver (1990, 1994) has inspired a corpus of adult attachment research based upon self report measures [26,27,28]. Whilst the elaboration of this significant and parallel research is beyond the scope of the present paper it is elegantly discussed by Feeney and Noller (1996). The classifications of the AAI are considered to be systematically related to infant patterns of attachment as assessed in the Strange Situation [22]; Secure (B), Avoidant (A), Resistant (C) and Disorganized/Disoriented (D) [29]. The rationale here is that infants internalize patterns of caregiving during repeated interactions with parents. These internalizations then become part of infants' representational models of relationships. The latter, in turn, shape both the infant's own behavior as well as its expectations of the behav-ior of others. The behavioral expression of infant patterns of attachment are considered to represent strategies for either mobilizing or else for restricting awareness of attachment related affects and cognitions. They may be summa-rized as follows:

1. Infants who are not ambivalent in seeking proximity, interaction or contact with the returning mother are classified Secure (Group B).

2. Infants who snub or avoid the mother upon reunion, and who show few if any signs of missing her during separation are classed as Insecure/Avoidant (Group A).

3. Infants who manifest anger and ambivalent toward their return-ing mother are classed Insecure/Ambivalent (C). They cry and seem to want contact but are unable to settle and return to play.

In developing the Insecure/Disoriented (D) category, Main & Solo-mon [29] noted that “…infants who could not be classified within the A, B, C system did not appear... to resemble one another in coherent organized ways. What these infants share in common was instead bouts or sequences of behavior which seemed to lack a readily observable goal, intention or expla-nation” (p. 122). The present study is one of a small number which, to date, incorporates the Insecure (D) category.

Of the three studies [6,7,30] which have assessed both maternal and paternal patterns of attachment, and have examined their respective concor-dances with infant-mother and infant-father attachment, Main et al. [6] and


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Van Ijzendoorn et al. [7] found stronger associations between mothers as compared with that of fathers and their infants. Steele et al. [30], using the adult Secure/Insecure dichotomy, found that paternal security was just as predictive as maternal security of infant secure attachment. Paternal insecu-rity though was found to be considerably less likely than maternal insecurity to increase the chance of an insecure infant-father attachment. Given that each was undertaken in a different country (USA, The Netherlands and Eng-land respectively), these studies may also be considered to provide cross-nation data. The latter have been shown to be associated with different cul-turally based approaches to childrearing and, subsequently, to different dis-tributions of infant-parent attachment categories despite the fact that mothers are the primary caretakers in most societies [31]. Only Steele et al., [30] used a prospective method. While a true predictive design remains the preferred scientific design, Van Ijzendoorn’s [16] meta-analysis found type of design (retrodictive, concurrent, predictive) did not explain variability in effect sizes across the 18 studies. Although both the adult Unresolved attachment cate-gory and the infant Disorganized/Disoriented attachment category predicted by it are important from theoretical, empirical and clinical perspectives [32, 33], they were either not used or not reported in these studies. All three stud-ies employed well educated, middle class, non-clinical samples wherein the mother was the (presumed) primary caregiver.

Clearly, given the dearth of studies which have examined the rela-tionship between paternal attachment status and infant-father attachment status, conclusive inferences are not possible. Rather, collectively, the three studies cited here raise several issues. The first relates to whether, during the first 18 months, the father’s history of attachment experiences may be less influential of the developing infant-father attachment relationship in primary maternal caretaking households. The second issue relates to whether, the AAI (irrespective of prenatal administration) reliably mobilizes and reflects the father’s mental state in terms of attachment relevant experiences. The third issue concerns whether a four way classification system will improve predicability by increasing the specificity of adult and infant attachment clas-sification. We undertook an Australian prospective study to examine the rela-tionship between security of expectant father’s representations of attachment and infant-father security at 15 moths using a four-way classification system. Based on attachment theory, the specific prediction was that there would be an association between the security or insecurity of prospective father’s men-tal models of attachment on the one hand and the security or insecurity of the infant's attachment to its father at 15 months on the other.

Method The initial sample comprised 66 couples in the last trimester of preg-

nancy, in which both partners were expecting their first child. Four couples withdrew after the prenatal data gathering stage due to geographic relocation


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in the case of three couples and due to separation in the remaining case. However their demographic data was retained to maximize numbers for demographic purposes. Thus the total, ongoing sample consisted of 62 cou-ples. This sample is described fully elsewhere [34]. Men’s mean age was 30 years (range, 22 - 43). Respondents were middle class and the majority were well educated. 85% of men had completed a minimum of senior high school years (years 11 and 12 in Australia), whilst 50% had some form of tertiary education. On a scale of Occupational Prestige [36] ranked 1-7, the mean paternal ranking was 4.1 (1=highest; judge, 1.2; 7= lowest; mortuary atten-dant, 6.8). 94% of couples were married at the time of recruitment; the re-mainder were in stable common law relationships. Due to financial con-straints, the current prediction study comprised a paternal sub-sample of 44. Comparative demographics of the paternal prediction sub-sample (N=44) and the remainder of the paternal sample were undertaken. There were no signifi-cant differences between these groups in age, educational level or occupa-tional status. However, the forty four prospective fathers in the prediction study had been married/together with their partner for longer than the pater-nal remainder, 5.83 years and 3.54 years respectively (pooled t=2.90, d.f. = 63, p < .002). Infants in the prediction study sub-sample comprised 21 males and 23 females.

Recruitment Couples were recruited from two major Sydney public teaching hos-

pitals, one major private teaching hospital and two privately operated ante-natal preparation organizations. Couples were informed that the study would investigate the process of the transition to parenthood and that an aspect of this aimed to clarify how the parents' experience of their own childhood may subsequently influence their parenting.

There were five stages in this longitudinal study: prenatal, 6, 11, 12 and 15 months. At each point a series of self-report measures (several re-peated) were completed and independently by father and mother. In the last trimester, they were separately interviewed in their own homes using the Adult Attachment Interview [12]. At 6 and 11 months home observations of mother, father and infant and of father and infant in free play were videoed. At 12 moths all infants were assessed with mother in the Strange Situation, then at 15 months they were all assessed with father. Only prenatal paternal AAI and father-infant attachment data (15 months) are reported here. Funds have not been available for further analysis at this stage.

Measures Adult Attachment Interview (AAI) [12]. The AAI is a semi-structured

audiotaped interview which assesses and classifies and adult’s “state of mind with respect to attachment” [13]. It has been described in the Introduction.


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Research assistants made transcripts anonymous and assigned new subject numbers to ensure that subsequent coding of infants in the Strange Situation Procedure would be blind. All coding was undertaken by the first author. Inter-rater agreement for four AAI categories was 80% (Kappa=.72, p<.001) on 20 randomly selected transcripts; representing 32% of the total sample (N = 62). The first author had received training in the scoring of the AAI by Mary Main, Mary Ainsworth and Erik Hesse.

Strange Situation Procedure (SS) [22]. This 20 minute standardized laboratory procedure has well established reliability and validity. Infants are observed responding to two brief separations from and reunions with the par-ent. Infants are assigned to categories on the basis of their behavior in the SS, with a particular focus on reunion behavior.

Inter-rater reliability was established with a coder unfamiliar with the project. Agreement for four primary classifications was k =.86 (p<.001). Both coders had received training in the scoring of the Strange Situation A, B and C categories from Alan Sroufe. Additionally, the first author has estab-lished inter-laboratory reliability with Alan Sroufe for A, B and C categories. Both coders attended a one week programme of instruction in D category coding provided by Main and Hesse [25]. The first author spent three weeks during 1993 working directly with Main and Hesse in order to establish reli-ability for D coding.

Results The data presented here pertain to the hypothesis that a prospective

father's working models of attachment can predict the nature of the infant's attachment to its father 15 to 18 months later.

Prospective paternal working models of attachment as a predictor of

infant attachment to father at 15 months There are several measures of association which permit an interpreta-

tion of percentage reduction in error (PRE) in predicting the dependent vari-able from knowledge of the independent variable. In effect, this is similar to the concept of variance explained. The Delta PRE statistic [37] is the most sophisticated of these [38]. The null hypothesis that prediction yields no error reduction (coefficient = 0) is tested against the alternate hypothesis that there is error reduction (coefficient > 0). In terms of the present study this is to say that knowing the prospective father’s AAI category reduces error in predict-ing his infant's attachment category over whatever predictive error reduction would obtain if prospective paternal AAI category was unknown. Traditional concordance rates are also reported.

A secure versus insecure dichotomy was created for both the four category AAI/SS cross-classification model and the traditional three category AAI/SS cross-classification model. Hence, four Del PRE analyses were con-ducted; each employing different levels of prediction specificity.


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The 4x4 Cross-Classification Model (Adult D/E/F/U and infant A/C/B/D attachment categories)

Assessing the predictive value of the full 4x4 cross-classification model has been a feature of this study. In employing the adult Inse-cure/Unresolved category as a predictor of infant Insecure/Disorganized status, it represents the most complex model.

Cell frequencies amongst prediction and error cells in the full 4x4 cross-tabulation model (40.4 PRE, p<.0001, concordance 56.8%) are shown in Table 1. The error in predicting the infant's attachment category (from amongst four) was reduced by 40.4% when prediction was made on the basis of knowing the assigned attachment category (from amongst four) of the pro-spective father. Underscored entries are prediction cells. Non-underscored entries are error cells.

Table 1. A 4 x 4 table of cross-classifications of infant and paternal attach-ment security (N = 44)

Infant Attachment Security A B C D Adult Attachment Security D 5 1 1 1 8 F 1 11 3 1 16 E 3 1 1 2 7 U 1 3 1 8 13 10 16 6 12 44

The concordance between adult E and infant C category was very

low at 14.3% suggesting that the adult E/Insecure/Preoccupied category may be a poor predictor of infant C/Insecure/Resistant status. On the other hand, consistent with prediction, prospective fathers who had received an Inse-cure/Unresolved (U) classification tended to have children who displayed an Insecure/Disorganized (D) attachment to their fathers.

The error in predicting infant security versus insecurity was reduced by 50.9% when prediction was made on the basis of knowing whether the prospective father's attachment status was secure or insecure (dichotomised from four categories). Table 2 shows the cell frequencies among the predic-tion and the error cells in this condition (50.9 PRE, p < .0003, concordance 77.2%).

Table 2. Table of dichotomised cross-classifications of infant and paternal attachment security (reduced from four categories) (N = 44)

Infant Attachment Security Secure Insecure Adult Secure 11 5 16 Attachment Insecure 5 23 28 Security 16 28 44


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The 3x3 cross-tabulation model (adult D/E/F and infant A/C/B cate-gories)

When prediction was made on the basis of knowing the assigned at-tachment category (from amongst three) of the prospective father, the error in prediction the infant's attachment category (from amongst three) dropped to the modest 29.7%. Table 3 shows the cell frequencies among the prediction and error cells in the 3 x 3 cross classification model (29.7 PRE, p < .007, concordance 54.5%).

Table 3. A 3 x 3 Table of cross-classifications of infant and paternal attach-ment security (N = 44)

Infant attachment security A B C Adult D 8 1 3 12 attachment F 1 14 4 19 security E 5 6 2 13 14 21 9 44

The error in predicting infant security was reduced by 45.1% when

prediction was made on the basis of knowing whether the father's attachment status was secure or insecure (dichotomised from three categories). Table 4 indicates the frequencies among the prediction and error cells in this condi-tion (45.1 PRE, p < .00014, concordance 72.7%).

Table 4. Table of dichotomised cross-classifications of infant and paternal attachment security (reduced from three categories) (N = 44)

Infant attachment security Secure Insecure

Adult attachment security Secure 14 5 19 Insecure 7 18 25 21 23 44

As in the four category model, the concordance rate between adult E

and infant C category was very low at 15.4%. Its effect in reducing the pre-dictive success in the 3 x 3 model is heightened because only two alternate predication categories remained.

All the predictive models described demonstrated significant predic-

tive success. These analyses suggest that, overall, knowledge of the nature of a prospective father's working models of attachment provides a good predic-tive criterion for his infant's attachment organization to him some 15-18 months later. However, the strongest prediction was achieved when both in-fant and paternal classifications were dichotomised to Secure versus Inse-cure. The disadvantage of this approach was the loss of specificity of predic-


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tion. An acceptable compromise was achieved in the 4 x 4 cross-classification model which yielded a 40.4 PRE, whilst preserving the maxi-mum specificity. In particular, this model highlights the usefulness of the paternal Unresolved category as a predictor of infant Disorganized/Diso-riented attachment to father. Nevertheless, a substantial degree of predictive error remains even considering the strongest predictive model.

Discussion A significant and moderate to moderately strong positive relationship

was found between a prospective father's developmental history on the one hand, and his infant's quality of attachment to him at fifteen months on the other. Thus, at the most molar level of analysis, and even before the child was born, it has been possible to distinguish between fathers who infants would develop a secure versus an insecure attachment relationship with them over the first fifteen months of their lives. Even at a category for category level of analysis, predicted relationships remained significant although less strong.

These findings are consistent with other studies which have investi-gated the relationship between adult and infant attachment organization using the AAI. Of the three studies which have investigated the paternal AAI/ in-fant SS relationship, Main et al. [6] found the association to be significant but less strong than the maternal AAI/ infant SS relationship. However, Steele et al. [30] found that paternal and maternal AAI security were just as predictive of infant attachment security. Van Ijzendoorn et al. [7] on the other hand, did not find the correspondence between paternal and infant at-tachment to be statistically significant although that between maternal and infant attachment was significant. However these latter authors stress that the post hoc methodology of assessing adult attachment several years after measuring infant attachment may have confounded their data. Taken collec-tively, findings suggest that the way parents perceive and verbally recollect their earliest and more current affectional ties directly influences the quality of the parent-infant attachment relationship, presumably because these per-ceptions or mental representations of attachment influence parental behavior toward the child.

The proportion of secure models of attachment (36% and 43% using the four way and the three way AAI classification system respectively) found amongst prospective fathers seems low for a normative sample. However, these findings fall within the range of Autonomous adult attachment classifi-cations reported by other investigators. For example, van Ijzendoorn et al. [7], using the three way classification system assigned 48% of their paternal sample (N=29) to the Autonomous category. The first author has discussed comparative findings more fully elsewhere [34]. Furthermore, in van Ijzen-doorn's [16] meta-analysis of 18 AAI-SS studies, data from the present in-vestigation were not found to be anomalous.


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Additional qualitative data which address possible stylistic differ-ences in AAI responses between fathers and mothers would be a useful means by which to advance understanding of mental processes associated with father-infant relationships. Van Ijzendoorn's [16] meta-analysis did not find that fathers were significantly more over-represented than were mothers in the D category. Anecdotally, interviewers did not report any differences between prospective fathers and their pregnant partners in the approach to the AAI. Resource constraints have prevented maternal AAI's being coded to date.

The present investigation is important for several reasons. First a pro-spective, longitudinal design using the four-way adult and infant attachment classification systems successfully predicted continuity in the nature and quality of father-child relations across generations. It therefore offers power-ful support for the attachment paradigm, for the validity of the AAI and for the importance of the father in the social-emotional development of his child.

The evidence is compelling that fathers independently influence the attachment relationship with their children [39] found there to be no relation-ship between relative parental involvement and the security of infant attach-ment. The findings of this study support those of Frodi et al. [39]. They sug-gest that even in primary maternal caretaking households, the father's history and mental representation of attachment experiences is equivalently influen-tial in determining the quality of the infant father attachment relationship as is mother's history for infant-mother attachment. We may therefore assume that the adult attachment related mental processes and their transmission are the same. This, of course, leaves open the question raised by Main et al. [6] of the existence in infancy of a hierarchical ordering in the organization of working models of attachment with favors the primary caretaker. The present findings cannot answer this question. They do, however, point to the salience for the child's socio-emotional development, of the father's attachment re-lated mental state, particularly given the secondary caretaker status of the fathers in this study. Relatedly, the positive predictive findings described here suggest that the AAI does reliably mobilize and reflect paternal attach-ment relevant mental states, and differences amongst them, hence supporting the validity of the AAI in a paternal sample.

A second important aspect of this study is that it is one of only a small number which has incorporated the adult Insecure/Unresolved category in a normal sample prediction study [40,25]. Of additional significance is that it is the first such prospective study with fathers. It therefore permits as-sessment of the contribution to prediction of a more highly specified cross-classification structure. In this regard, and with reference to infant-father at-tachment outcomes, it is noteworthy that only 36% of the strange situation relationships were classified as Secure (see Table 1). Logically, the addition of another category will reduce numbers in the other categories. Main [41] has suggested that the introduction of the infant Disorganized category has generally had the effect of reducing the number of infants classified as hav-


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ing Secure attachment relationships. For example, Main and Solomon [29] report that in the Main and Weston [5] investigation (which included assess-ment of infant-father attachment) 13 out of 19 infants judged difficult to clas-sify in the latter investigation of 152 strange situation procedures “...would have been identified as Secure. with the parent had standard classification procedures been utilized” [25].

In this study, removing the Insecure/Disorganized category from analysis resulted in 48% of infants being assessed as having Secure attach-ment relationships with their fathers. This finding is consistent with the Main et al. [5] data and with Main's [29] assertion. Although these proportions of secure-infant father attachment relationships may appear small they are not inconsistent with the van Ijzendoorn and Kroonenberg [31] meta-analysis of cross-cultural patterns of attachment. Additionally, the secure pattern of in-fant-father attachment emerged as modal in both the 3x3 and in the 4x4 cross-classification models (see Tables 2 and 4).

Relatedly, 27% (N=12) of infants were classified as exhibiting Inse-cure/Disorganized attachment behavior towards their fathers. This proportion is consistent with Ainsworth et al. [40] who found a similarly high propor-tion of D infants (33%) in their unselected sample of mother-infant dyads. Interestingly, in the present study, the only Insecure/Disorganized infants with an alternate Secure classification were those infants sub-classified as B4 (N=5); a group whose status within the Secure classification has been ques-tioned [42,43].

Paternal Unresolved status (resulting from loss through death in every case but one) was found to be a moderate predictor of infant Inse-cure/Disorganized status (61.5% concordance)1. This finding is comparable with that of Main & Hesse [25] who reported 60% agreement in their se-lected sample of 53 mother-infant dyads. Ainsworth & Eichberg [40], on the other hand reported 100% agreement in their study of 45 unselected mother-infant dyads. However, perhaps the most important point is that in the three studies (including this one), parents who either had not experienced loss of a significant figure or, if they had, appeared to have resolved that loss, did not tend to have infants judged Disorganized with them in the Strange Situation. It appears then that parental lack of resolution of mourning may be a greater risk-factor for unfavorable developmental sequelae in children than loss per se. Main et al. [6] and Cassidy [38] have reported that six year old children who, as infants were judged Insecure/Disorganized with a parent demon-strated controlling or punitive behavior towards that parent. Additionally, they engaged in developmentally inappropriate role-inverting parent-child

1 Of the 62 fathers, 51 (83%) had, during their childhood, adolescence or young adulthood, experi-enced the loss through death of a parent or other emotionally significant person. Although other, more sym-bolic losses (such as those occurring in relation to divorce) are considered important aspects of the individual's attachment history, they are not considered in determining Unresolved status.


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interactions. Recent theorizing about the nature of the developing mental state of children classified as Disorganized/Disoriented in infancy speculates that these children may, as adults, be more vulnerable to the development of dissociative mental disorders [44].2 If the nature of the father's relationship with his child has the potential to act as a protective or as a vulnerability fac-tor in the child’s development, as is suggested by attachment theory and re-search [17,5,18] then the child with a Disorganized attachment relationship to an Unresolved father may be particularly vulnerable.

In this study, while fathers or infants who would develop a secure, an Insecure/Avoidant or an Insecure/Disorganized attachment were distinguish-able before the child was born, this was not the case for the father whose child would develop an Insecure/Resistant attachment. Fonagy et al's [15] prospective study of low-risk, middle class maternal-infant dyads using the 3 x 3 cross-classification model also found that the maternal Insecure/Preoccupied status was a poor predictor of infant Insecure/Resistant attachment. On the other hand, in a high risk sample, Ward, Botyanski, Plunket & Carlson [46] found good predicability in the adult Insecure/Preoccupied category, as did Main (personal communication) in her low risk sample. Main & Solomon [33] have noted that the infant Insecure/Resistant pattern may be less “well organ-ized” than the other attachment patterns. This may conceivably also be the case for the adult Insecure/Preoccupied mental state. Note that in the 4 x 4 cross-classification model, paternal preoccupied status was a good predictor of overall infant Insecure status (85.7% concordance - A, D, C). Clearly, fur-ther studies are required to clarify the predictive status of this category. This study has demonstrated the good predicability of the four-way cross-classification model (40.4 PRE) compared to the more modest predicability of the three-way cross-classification system (29.7 PRE). The power of the former model rested on the sound predictive performance of the Secure, the Insecure/Dismissing and the Insecure/Unresolved categories on the one hand and the poor predictive performance of the Insecure/Preoccupied categories on the other. To date, few studies have employed the Unresolved category. However, the present findings highlight its importance for future investiga-tions of the relation between AAI and SS classifications, particularly in light of increasing and compelling arguments and findings which appear to impli-cate the adult Unresolved and infant Disorganized/Disoriented attachment states with relational maladaptation.

Third, this investigation is important because it has been conducted in Australia where Adult Attachment Interview research has not been re-ported to date. The success in prediction in an Australian paternal sample suggests that the AAI is a culturally valid instrument for Australian use, at

2 This speculation is receiving some empirical support in recent [45] and current investigations ex-

amining the relationship between Unresolved status and the psychopathology of dissociative disorders [33,44].


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least with middle class male populations. It argues for the universality of the states of mind with respect to attachment which the AAI claims to tap.

Due to the dearth of paternal AAI studies and due to necessary de-sign constraints, the findings of this study require cautious interpretation. In the case of non-concordant father-infant relationships, repeated measures analysis of self report data suggested a trend for Secure fathers with Inse-curely attached infants to have experienced greater intra and interpersonal strain over the transition to parenthood compared with Insecure fathers whose infants were Securely attached to them at 15 months. Future studies with larger, more culturally and socio-economically diverse populations could examine better the potentiating roles of both psychological stress and psychological resilience. Additionally, the degree to which prediction failure may have resulted from procedural or coding errors on the one hand or from altered paternal representations of attachment across the transition to parent-hood is not known. The latter contingency could be addressed by further pro-spective studies employing a pretest-retest design.

These limitations notwithstanding, this investigation has provided important prospective data which supports the attachment paradigm in dem-onstrating that lawful relations do exist between the way fathers construct their own developmental history on the one hand and how they go about nur-turing their child on the other. Additionally, the AAI was shown to be able to discriminate prenatally, those fathers who children would subsequently be-come Securely or Insecurely attached to them. In particular, the use in this study of the adult Unresolved/infant Disorganized categories has provided the first evidence of a prospective empirical link between the two in a low-risk paternal sample. Finally, in focusing on the father-infant dyad valuable new insights have been provided into how the father's perception of this own developmental history shapes the nature of this important relationship.

Acknowledgments The authors wish to thank Mary Main for her thoughtful comments on

an earlier version of this paper, Diane Benoit and John Lord for reliability checks on the AAI and infant SSP respectively, and Alan Taylor for his statisti-cal support.

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44. Liotti G. Disorganized attachment and dissociative experiences: an illus-tration of the developmental-ethological approach to cognitive therapy. In: H. Rosen, KT Kuehlwein (Eds.). Cognitive therapy in action. San Francisco: Jossey-Bass. In press. 2006.

45. Ross CA. Multiple personality disorder: diagnosis, clinical features and treatment. New York: John Wiley & Sons; 1989.

46. Ward MJ, Botyanski NC, Plunket SW, Carlson A. Concurrent validity of the AAI for adolescent mothers. Paper presented at the 1991 Biennial Meeting of the Society for Research in Child Development, April 18-20, Seattle (Washington).

___________________ Marija RADOJEVIĆ, klinički psiholog, Služba za zaštitu mladih i porodice, bolnica Hornzbi i Ku-ring-gaj, Sidnej Grem Rasel, Fakultet bihejvioralnih nauka, Univerzitet Makvari, Australija

Marija RADOJEVIC, PhD, Senior Clinical Psychologist, Adolescent and Family Service, Hornsby and Ku-ring-gai Hospital, Sydney and Graeme Russell PhD, Associate Professor of Psychology, School of Behavioral Sci-ences, Macquarie University, Australia


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Istraživački rad

UDK: 616. 89-008. 441 : 355.48(497.11)“1999”

POVEZANOST POSTTRAUMATSKOG STRESA I KVALITETA ŽIVOTA KOD GRAĐANA

POSLE VAZDUŠNIH NAPADA

Jelena Janković Gavrilović1,2, Dušica Lečić Toševski2, Olga Čolović2, Sara Dimić2, Veselinka Šušić3,

Milica Pejović Milovančević2, Smiljka Popović Deušić2, Stefan Priebe1

1 Odeljenje za socijalnu i komunalnu psihijatriju Barts i Medicinski fakultet

Queen Mary u Londonu, London, Velika Britanija 2 Institut za mentalno zdravlje, Beograd, Srbija i Crna Gora 3 Srpska Akademija nauka i umetnosti, Srbija i Crna Gora

Apstrakt: Iako su kvalitet života i posttraumatski stres detaljno proučavani, njihov međusobni odnos je retko ispitivan. Ovo istraživanje proučava odnos između posttraumatskog stresa i kvaliteta života u relativno homogenoj i neselektivnoj grupi građana koji su bili izlo-ženi vazdušnim napadima. Kvalitet života (MANSA), posttraumatski stres (IES) i depresi-ja/anskioznost (SCL-90-R) ispitivani su kod dve grupe studenata medicine (N1=139, N2=475) posle jedne, odnosno, dve godine vazdušnih napada u Srbiji i Crnoj Gori. Rezultati pokazuju slabu do srednje izraženu vezu između posttraumatskog stresa i subjektivnog doživljaja kvali-teta života. Nakon ispitivanja stepena depresivnosti i anksioznosti, jedino je veza između post-traumatskog stresa i zadovoljstva mentalnim zdravljem statistički značajna u obema grupama. Čini se da anksioznost i depresija imaju uticaja – u velikoj meri, ali ne potpuno, na vezu izme-đu posttraumatskog stresa i ličnog doživljaja kvaliteta života.

Ključne reči: posttraumatski stres, kvalitet života, vazdušni napadi, građani


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Uvod Koncept kvaliteta života je sve popularniji u psihijatrijskim istraživa-njima u poslednje dve decenije [1] i postoji dosta literature koja se odnosi na kvalitet života različitih grupa psihijatrijskih pacijenata [2]. Iako ne postoji de-finicija kvaliteta života koja je univerzalno prihvaćena [3], većina stručnjaka se slaže da postoje subjektivni i objektivni pokazatelji kvaliteta života i da su sub-jektivni oni koji su ključni. Koncept subjektivnog kvaliteta života – dalje u tekstu SKŽ (subjective quality of life – SQOL) fokusira se na individualnu per-cepciju i procenu kvaliteta njegovog ili njenog kvaliteta života [4,5]. U proceni kvaliteta života koristi se veliki broj skala – od onih koje se odnose na zdravlje, preko onih koje su specifične za bolest, do opštih. U psihijatrijskim istraživanjima, u skladu sa opštim konceptom, kao indikatori SKŽ ustanovljeni su procena zado-voljstva životom u celini i procena zadovoljstva specifičnim aspektima života [6]. U opštoj populaciji, kao i u uzorku pacijenata, simptomi raspoloženja označeni su kao najznačajniji i stalni činioci koji utiču na SKŽ. Različita is-traživanja pokazuju niže rezultate SKŽ kod ispitanika sa višim stepenom de-presivnih simptoma [7,8,9]. Zbog toga treba kontrolisati uticaj simptoma ras-položenja prilikom procene SKŽ. Pa ipak, opšta varijansa između simptoma raspoloženja i SKŽ retko prelazi 25% i SKŽ se ne može smatrati pratećom pojavom depresivnih simptoma [5]. Iako postoji obimna literatura o posttraumatskom stresu i kvalitetu života, mali broj istraživanja proučava vezu između ova dva pojma [4,10]. Ovo je u suprotnosti sa definicijom posttraumatskog stresnog poremećaja u DSM IV koja navodi uticaj društvenog funkcionisanja kao kriterijum dijag-noze. Koncept društvenog funkcionisanja različit je od kvaliteta života, ali se preklapa sa njim i u vezi je sa njim. Osim toga, pokazalo se da kod generali-zovanog anksioznog poremećaja i nakon utvrđivanja postojanja psihopato-loških fenomena, postoji visok stepen oštećenja. Rezultati Nacionalne vijet-namske studije o ponovnom prilagođavanju veterana muškog i ženskog pola, pokazuje da su ispitanici sa PTSP imali značajno povišen rizik od smanjenog funkcionisanja u različitim aspektima života [12,13]. Najveći broj retkih is-traživanja koja se bave kvalitetom života i mentalnim zdravljem posle stres-nog događaja posmatrala su ili psihijatrijske pacijente ili veterane. Zdravi ljudi retko su bili sistematski ispitivani. U ovom istraživanju posttraumatski stres ispitivan je u dve relativno homogene i neselektivne grupe studenata medicine, nakon jedne i nakon dve godine od vazdušnih napada na Beograd.

Napadi su trajali od 24. marta do 9. juna 1999. godine, izvodili su se skoro svake noći i uzrokovali su civilne žrtve širom Srbije i Crne Gore. Pro-cenjuje se je da je broj civilnih žrtava iznosio oko 1,200 [14]. Ovo istraživanje postavlja sledeća pitanja:

1. Kakva je povezanost posttraumatskog stresa i kvaliteta života? 2. Da li u ovoj povezanosti posreduju simptomi anksioznosti i depre-

sivnosti?


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Metod Uzorak

Grupa A sastoji se od 139 od ukupno 141 studenta četvrte godine Medicinskog fakulteta koji prate nastavu u jednoj psihijatrijskoj ustanovi u Beogradu (95 žena, 44 muškaraca), starosti između 21 i 28 godina (srednja vrednost 23.8 god.; SD=1.3). U vreme izvođenja istraživanja, u proleće 2000. godine, oko godinu dana nakon vazdušnih napada, četvoro studenata živelo je sa partnerom i niko od njih nije imao decu. Nivo posttraumatskog stresa, načini za prevazilaženje stresa i lične osobine ove grupe prikazane su na dru-gom mestu [14,15,16]. Grupa B sastoji se od 475 od oko 600 studenata druge godine medi-cine koji slušaju nastavu na Institutu za fiziologiju Medicinskog fakulteta u Beogradu (334 žene i 141 muškarac), starosti između 20 i 29 godina (srednja vrednost 21.1 god.; SD=0.7). U vreme izvođenja istraživanja, u proleće 2001. godine, oko dve godine nakon vazdušnih napada, šest studenata živelo je sa partnerom, i četvoro od njih imalo je decu. Svi ispitanici bili su izloženi vazdušnim napadima, tokom proleća 1999, kao civili. Pošto je nezavisni istraživač predstavio ciljeve istraživanja studentima, dobijen je pristanak za istraživanje.

Instrumenti Kvalitet života ocenjivan je pomoću Kratke Mančesterske skale za procenu kvaliteta života (Manchester Short Assessment of Quality of Life – MANSA) [18]. MANSA je kratka skala za procenu opšteg nivoa kvaliteta života koja se koristi u mnogim ispitivanjima mentalnog zdravlja. Ova skala ima sličnosti sa Intervjuom o kvalitetu života [19,20] i Lankaširskim profi-lom kvaliteta života (Lancashire Quality of Life Profile – LQLP), ali je i mnogo preciznija od njih [21]. Sve ove skale imaju isti koncept i veoma slič-na pitanja koja se tiču zadovoljstva, uključujući i skalu od 1 do 7, na kojoj 1 označava nepovoljni pol, a 7 povoljni pol. Nezavisno od prikupljanja podata-ka o ličnim detaljima i objektivnim okolnostima života, MANSA sadrži šes-naest pitanja od kojih se četiri smatraju “objektivnim”, a ostalih dvanaest su procena zadovoljstva životom u celini i u specifičnim područjima života. Ko-relacije između SKŽ zbira na upitnicima MANSA i LQLP bile su 0.83 ili više; Kronbah alfa koeficijent za ocenu zadovoljstva bio je 0.74, a udruže-nost sa psihopatologijom je bila u skladu sa rezultatima dobijenim na LQLP, kao što se i navodi u literaturi [18]. Primenjena je Skala uticaja događaja (The Impact of Event Scale – IES) [21], upitnik od petnaest stavki, koji meri simptome posttraumatskog stresa, nametanje i izbegavanje. Anksiozni i depresivni simptomi procenjivani su Preglednom listom simptoma (Symptom Checklist 90-R – SCL-90-R9) – instrumentom od de-vedeset stavki za samoprocenu opšte psihopatologije na deset subskala [22].


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Statistička analiza T-test i Pirsonov koeficijent korelacije korišćeni su da bi se ispitala

veza između SKŽ i posttraumatskog stresa. U sledećem koraku, bivarijantne korelacije koje su dostigle statističku značajnost proveravane su u odnosu na anksioznost i simptome depresivnosti tako što su izračunavani parcijalni koe-ficijenti korelacije, eliminišući uticaj anksioznosti i depresivnosti na rezultate IES i SQOL. Kako bi se smanjila greška I tipa a priori izračunavali smo par-cijalne koeficijente samo kada je bivarijantna korelacija bila značajna.

Rezultati Kvalitet života i zbir simptoma

Srednje vrednosti zbira zadovoljstva životnim oblastima (MANSA), IES i depresivnost (SCL-90R) prikazani su na Tabeli 1. Tabela 1. Srednje vrednosti i standardne devijacije za zadovoljstvo životnim oblastima (MANSA), IES, depresija i anksioznost (SCL-90R)

Grupa A (N=139)

Grupa B (N=475)

Život u celini 4.2 (0.9) 4.1 (1.1) Obrazovanje/edukacija 4.6 (1.1) 4.3 (1.1) Finansije 3.8 (1.3) 3.9 (1.4) Prijateljstva 5.2 (1.0) 5.0 (1.3) Slobodne aktivnosti 4.1 (1.3) 3.5 (1.4) Stanovanje 5.1 (1.0) 5.0 (1.3) Sigurnost 4.8 (1.2) 5.0 (1.2) Ljudi s kojima živi 5.4 (1.0) 5.4 (1.2) Seksualni život 4.6 (1.4) 4.3 (1.6) Odnosi sa porodicom 5.5 (1.1) 5.5 (1.2) Zdravlje 5.3 (1.1) 5.1 (1.2) Mentalno zdravlje 5.8 (0.9) 5.6 (1.2) Srednji zbir 4.9 (0.6) 4.7 (0.7) IES 13.6 (14.2) 20 (17) SCL-90R depresija 0.7 (0.7) 1.2 (0.8) SCL-90R anksioznost 0.6 (0.6) 1.1 (0.8)

Odgovori na pitanja o objektivnim pokazateljima kvaliteta života ocenjivani su upitnikom MANSA i prikazani u Tabeli 2. Tabela 2. Odgovori na pitanja koja se odnose na objektivni kvalitet života studenata (u procentima)

Grupa A Da Ne

Grupa B Da Ne

Da li imate bliskog prijatelja? 94.9 5.1 89.4 10.6 Da li ste posetili prijatelja tokom prošle nedelje? 93.4 6.6 87.5 12.5 Da li ste bili optuženi za zločin prošle godine? 0 100 0.6 99.4 Da li ste bili svedok fizičkog nasilja prošle godine? 1.4 98.6 2.1 97.9


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Univarijantna prognoza U obe grupe IES visoko značajno korelira sa anksioznošću i depresiv-nošću. Koeficijent korelacije između IES i anksioznosti je r=0.62 (p<.001) u grupi A, i 0.47 (p<.001) u grupi B. Koeficijenti korelacije između IES i dep-resije su 0.56 (p<.001) u grupi A, i 0.46 (p<.001) u grupi B. Tabela 3. pokazuje bivarijantne korelacije između IES zbira i zadovolj-stva posebnim životnim domenima. Svi značajni koeficijenti korelacije su nega-tivni, pokazujući da je viši nivo simptoma povezan sa nižim SKŽ. Tabela 3. ta-kođe sumira parcijalne korelacije, npr. korelaciju između IES i SKŽ zbira, s tim što je eliminisan zajednički uticaj anksioznosti i depresivnosti na obe varijable. Tabela 3. Koeficijenti korelacije i stepeni značajnosti bivarijantne korelacije i parcijalne korelacije – ispitivani u odnosu na depresiju i anksioznosti iz SCL-90R između IES – i zadovoljstva životnim domenima MANSA (parcijalna kore-lacija je izračunavana samo za korelacije koje su dostizale značajni nivo u biva-rijantnim korelacijama)

Grupa A (N=139) Grupa B (N=475) Bivarijantna

korelacija IES

Parcijalnakorelacija

IES

Bivarijantna korelacija

IES

Parcijalna korelacija

IES Život u celini -.16 ns -.22 *** -.05* Obrazovanje/edukacija -.11 ns -.15*** -.03 ns Finansije -.10 ns -.05 ns Prijateljstva -.16 ns -.13** -.03 ns Slobodna aktivnosti -.10 ns -.13** .03 ns Stanovanje -.02 ns -.09* -.04 ns Sigurnost -.14 ns -.23*** -.16*** Ljudi sa kojima živi -.16 ns -.15*** -.10* Seksualni život .04 ns -.14** -.02 ns Odnos sa porodicom -.25** -.17* -.14** -.07 ns Zdravlje -.29*** -.15 ns -.17*** -.03 ns Mentalno zdravlje -.42*** -.23** -.33*** -.14** Srednji zbir -.26** -.07 ns -.30*** -.09*

Ns Bez značaja * p<0.05 ** p<0.01 *** p<0.001 Kada je ispitivan uticaj anksioznosti i depresivnosti, najveći broj ko-relacija nije uspeo da dostigne statističku značajnost. Jedina korelacija IES koja ostaje značajna je ona između zadovoljstva odnosima u porodici i men-talnim zdravljem u grupi A, i zadovoljstva ljudima sa kojim živi, sigurnošću, mentalnim zdravljem i srednjom vrednosti zbira u grupi B. Prema tome, za-dovoljstvo mentalnim zdravljem jedino je SKŽ područje života koje ostaje značajno u obe grupe studenata kada je uticaj anksioznosti i depresivnosti kontrolisan.


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Što se tiče pokazatelja objektivnog kvaliteta života prikazanih u Ta-beli 2, test za vezu sa IES pokazuje samo jedan statistički značajan rezultat: u grupi B, studenti koji su bili žrtve fizičkog nasilja, imali su viši IES zbir (t=2.44, df=471, p<.05).

Diskusija Veza između posttraumatskog stresa i kvaliteta života ispitivana je u dve grupe studenata. Uzorci su bili relativno veliki, neselektivni i homogeni, uz uvažavanje različitih činilaca kao što su uzrast, obrazovanje, i zaposle-nost. Stoga nije bilo potrebe da se kontroliše uticaj tih činilaca. Metodološka snaga istraživanja je u tome što su svi ispitanici bili izloženi istim stresoge-nim događajima, i vremenski interval između događaja i ispitivanja u okviru svake grupe bio je isti. Nivo pottraumatskog stresa varira u okviru obe grupe i srednji SKŽ je bio sličan onome nađenom kod drugih nekliničkih uzoraka [24]. Odslika-vajući njihovu homogenost u odnosu na životne okolnosti, uzroci pokazuju vrlo ograničeno neslaganje u odnosu na objektivne pokazatelje kvaliteta ži-vota. Varijable sa tako malim nivoom neslaganja najverovatnije nisu u zna-čajnoj korelaciji sa drugim parametrima. Jedina statistički značajna veza koju smo identifikovali je viši IES zbir kod ispitanika koji su bili žrtve nasilja u poslednjih godinu dana. Iskustvo doživljenog nasilja može samostalno da uzrokuje posttraumatski stres, ili u kombinaciji sa delovanjem stresogenog događaja tokom vazdušnih napada. Neka istraživanja ukazuju da izlaganje većem broju traumatskih iskustava povećava mogućnost odgovora u skladu sa simptomima posttraumatskog stresa [25]. U obe grupe postojala je korelacija slabe do srednje jačine između IES zbira i SKŽ ocene. Zbog većeg uzorka u grupi B, veći broj koeficijenata korelacije dostigao je statističku značajnost. Srednja vrednost zbira ocene zadovoljstva može se posmatrati kao najpouzdanija vrednost SKŽ skora [12]. Postojala je sugestija da se, osim u slučaju kada postoji specifična hipoteza u odnosu na pojedinačno područje života, prvo testira srednja vrednost zbira. Samo kada postoji značajan rezultat u pogledu srednje vrednosti zbira treba analizirati i interpretirati rezultate za pojedina područja života. U obe grupe srednja vrednost zbira zaista značajno korelira sa IES i koeficijenti su slične veličine. Veze su postojane, iako se srednje vrednosti nivoa posttraumatskog stresa razlikuju između dve grupe zbog razloga koje nismo u stanju da istra-žimo na osnovu podataka sakupljenih prilikom istraživanja. Različit vremenski period između stresogenog događaja i ispitivanja, tj. jedna godina nasuprot dve godine, izgleda da nema ključni uticaj na pove-zanost posttraumatskog stresa i SKŽ. Međutim, izgleda da je ova jasna pove-zanost – uglavnom, ali ne potpuno – pod uticajem simptoma anksioznosti i depresivnosti. Posttraumatski stres može biti povezan sa simptomima raspo-loženja i anksioznosti za koje se zna da imaju uticaj na ocenu SKŽ. Poveza-nost posttraumatskog stresa sa zadovoljstvom ispitanika sopstvenim mental-


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nim zdravljem najjača je u bivarijantnim testovima, i jedina je koja ostaje statistički značajna u obe grupe nakon ispitivanja simptoma raspoloženja i anksioznosti. Ova povezanost, takođe, može biti kvalitativno različita, tako da je prateći simptomi raspoloženja i anksioznosti ne mogu potpuno objasniti. Nedostatak ovog istraživanja je u pristupu poprečnog preseka, koji ne dozvoljava da se izvedu zaključci na osnovu uzročne veze. Viši nivoi post-traumatskog stresa, uglavnom posredovani depresivnošću i anksioznošću, utiču na SKŽ i, obrnuto, niži SKŽ može imati negativan uticaj na simptome. Buduće prospektivno longitudinalno istraživanje trebalo bi da se bavi uzroč-nošću.

Zaključak Rezultati ukazuju da je posttraumatski stres povezan sa SKŽ u relativ-

no homogenim i neselektivnim grupama građana koji su doživeli stresogen i potencijalno traumatičan događaj. Rezultati se slažu u dva nezavisna, ali slič-na uzorka. S druge strane, trebalo bi ih ponoviti u drugim grupama ili kon-tekstima. U budućim istraživanjima bilo bi korisno ispitati pokazatelje kvalite-ta života u uzorcima u kojima ispitanici imaju posttraumatski stres. Takvo ispitivanje može pokazati da SKŽ utiče na posttraumatski stres, ili je njegova relevantna posledica, ili i jedno i drugo, i identifikovati ulogu simptoma ras-položenja u ovoj povezanosti. U svakom slučaju, simptomi anksioznosti i depresivnosti moraju se smatrati činiocima posredovanja. Priroda ove pove-zanosti još uvek nije jasna, i dalje sistematično ispitivanje, primenom kvanti-tativnih i kvalitativnih metoda, neophodno je za razumevanje procesa koji su u korenu ovih povezanosti. Istraživanja intervencija trebalo bi da ispitaju da li terapijske intervencije primarno za cilj treba da imaju poboljšanje posttra-umatskog stresa ili simptoma raspoloženja da bi uticali na SKŽ, ili bi pobolj-šani SKŽ naknadno vodio do smanjenja nivoa anksioznosti, depresivnosti i posttraumatskog stresa.

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Research article

UDK: 616. 89-008. 441 : 355.48(497.11)“1999”

ASSOCIATION OF POSTTRAUMATIC STRESS AND QUALITY OF LIFE IN CIVILIANS AFTER AIR ATTACKS

Jelena Jankovic Gavrilovic1,2, Dusica Lecic Tosevski2,

Olga Colovic2, Sara Dimic2, Veselinka Susic3, Milica Pejovic Milovancevic2,

Smiljka Popovic Deusic2, Stefan Priebe1

1 Unit for Social and Community Psychiatry, Barts and the London School of Medicine, Queen Mary, University of London, United Kingdom

2 The Institute of Mental Health, University of Belgrade, Belgrade, Serbia and Montenegro

3 Serbian Academy of Science and Art, Serbia and Montenegro

Abstract: Although quality of life and posttraumatic stress have been extensively studied, their relationship has rarely been investigated. This study explored the relationship between posttraumatic stress and quality of life in – relatively homogeneous and non-selective – groups of civilians who had been exposed to air attacks. Quality of life (MANSA), posttraumatic stress (IES), and depression and anxiety (SCL90-R) were assessed in two groups of medical students (N1=139, N2=475), one and two years respectively after air at-tacks in Yugoslavia. Results show weak to moderate associations between posttraumatic stress and subjective quality of life scores. After controlling for depression and anxiety, only the association between posttraumatic stress and satisfaction with mental health remains sta-tistically significant in both groups. Anxiety and depression appear to mediate – largely, but not fully - the association between posttraumatic stress and subjective quality of life.

Key words: posttraumatic stress, quality of life, air attacks, civilians


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Introduction The concept of quality of life has become increasingly popular in

psychiatric research over the last two decades [1], and there is a wide range of literature on quality of life findings in different groups of psychiatric pa-tients [2]. Although no single definition of quality of life has been univer-sally accepted [3], most experts agree that there are subjective and objective indicators of quality of life and that the subjective ones are central. The con-cept of subjective quality of life (SQOL) centres on the individual’s percep-tion and appraisal of the quality of his or her own life [4,5]. Numerous scales have been used to assess quality of life and the constructs range from health related and disease specific ones, to more generic ones. In psychiatric re-search, ratings of satisfaction with life as a whole and with different life do-mains have been established as indicators of SQOL in line with a generic concept [6].

In the general population, as well as in patient samples, mood symp-toms have been identified as the most significant and consistent factor influ-encing SQOL. Various studies indicate lower SQOL scores in subjects with higher degrees of depressive symptoms [7,8,9]. Thus, the influence of mood symptoms should be controlled for in studies on SQOL. Yet, the common variance between mood symptoms and SQOL rarely exceeds 25%, and SQOL cannot be just regarded as an epiphenomenon of depressive symptoms [6].

Even though the literature on both posttraumatic stress and quality of life is vast, there has been relatively little research on the association of the two [4,10]. This is despite the definition of Posttraumatic Stress Disorder in DSM IV that mentions impact on social functioning as a criterion for the di-agnosis. Social functioning is a concept different from, but related to and overlapping with quality of life. In addition, it has been shown that general anxiety disorder is associated with high impairment even after controlling for other psychopathology [11]. Research from the National Vietnam Readjust-ment Study, both of male and female veterans, showed that subjects with PTSD had significantly higher risk of diminished functioning in several as-pects of life [12,13]. Most of the few studies on quality of life and mental health after a stressful event were conducted either in psychiatric patients or veterans. Non-patient civilian groups have rarely been systematically stud-ied.

In this study, posttraumatic stress was assessed in two – relatively homogeneous and non-selective – groups of medical students, one year and two years after experiencing air attacks in Belgrade.

The attacks lasted from March 24 to June 9, 1999, occurred almost every night during that period of time and resulted in casualties among civil-ians throughout Serbia and Montenegro. The number of civilian deaths has been estimated at around 500 [14].


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The study addressed the following questions: 1. What is the association between posttraumatic stress and quality

of life? 2. Is the association mediated through anxiety and depressive

symptoms? Method Sample Group A consists of 139 out of 141 fourth year medical students in

one psychiatric teaching hospital in Belgrade (95 women, 44 men). The age ranged from 21 to 28 years (mean=23.8; SD 1.3). At the time of the study in spring 2000 approx. 1 year after the air attacks, four students lived with a partner and none had children [15]. The level of posttraumatic stress, coping strategies and personality characteristics of this group are presented else-where [15,16,17].

Group B consists of 475 out of approximately 600 second year medi-cal students taking a course at the Institute of Physiology in Belgrade (334 women, 141 men). Their age ranged from 20 to 29 years (mean=21.1; SD 0.7). At the time of the study in spring 2001 approx. 2 years after the air at-tacks, six students lived with a partner and four had children.

All of the subjects were medical students at the University of Bel-grade’s School of Medicine, and all had been exposed to air attacks as civil-ians in spring 1999.

After a complete description of the study by an independent re-searcher to the students, informed consent was obtained.

Instruments Quality of life was assessed on the Manchester Short Assessment of

Quality of Life [18]. The MANSA is a brief instrument for obtaining a ge-neric construct of quality of life widely used in mental health service re-search. It is similar to, but much more concise than the Quality of Life Inter-view [19,20], and the Lancashire Quality of Life Profile (LQLP) [21]. All of these tools share the same concept and have very similar satisfaction ques-tions including 1 to 7 rating scales with 1 being the unfavourable and 7 the favourable end of the scale. Apart from collecting personal details and objec-tive circumstances of life, the MANSA contains 16 questions of which four are considered “objective” and 12 are ratings of satisfaction with life as a whole and different life domains. Correlations between SQOL scores on MANSA and LQLP were all 0.83 or higher; Cronbach’s alpha for satisfaction ratings was 0.74, and association with psychopathology is in line with results for LQLP as reported in the literature [18].


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The Impact of Event Scale [22], a 15-items questionnaire that meas-ures intrusion and avoidance symptoms of posttraumatic stress was adminis-tered.

Anxiety and depressive symptoms were self-rated on the Symptom Checklist 90-R [23] – a 90 items instrument for self-rating of general psy-chological symptoms on 10 sub-scales.

Statistical Analysis T-tests and Pearson’s correlation coefficients were used to explore

the association between SQOL and posttraumatic stress. In a next step, bivariate correlations that reached statistical significance were controlled for anxiety and depressive symptoms by calculating partial correlation coeffi-cients, with the influence of anxiety and depression on both IES and SQOL scores eliminated. In order to reduce Type I error a priori we calculated par-tial correlations only when the bivariate correlation was significant.

Results Quality of life and symptom scores Mean scores for satisfaction with life domains (MANSA), IES and

depression (SCL-90R) are summarised in Table 1.

Table 1. Mean scores and Standard Deviations (SD) for satisfaction with life domains (MANSA), IES, depression and anxiety (SCL-90R)

Group A (N=139) Group B (N=475) Life as a whole 4.2 (0.9) 4.1 (1.1) Training/education 4.6 (1.1) 4.3 (1.1) Finances 3.8 (1.3) 3.9 (1.4) Friendships 5.2 (1.0) 5.0 (1.3) Leisure activities 4.1 (1.3) 3.5 (1.4) Accommodation 5.1 (1.0) 5.0 (1.3) Safety 4.8 (1.2) 5.0 (1.2) People living with 5.4 (1.0) 5.4 (1.2) Sex life 4.6 (1.4) 4.3 (1.6) Relationship with family 5.5 (1.1) 5.5 (1.2) Health 5.3 (1.1) 5.1 (1.2) Mental health 5.8 (0.9) 5.6 (1.2) Mean score 4.9 (0.6) 4.7 (0.7) IES 13.6 (14.2) 20 (17.4) SCL-90R depression 0.7 (0.7) 1.2 (0.8) SCL-90R anxiety 0.6 (0.6) 1.1 (0.8)

Answers to the questions on objective quality of life indicators as as-

sessed in the MANSA are shown in Table 2.


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Table 2. Answers to the questions that addressed objective quality of life-percent of students

Group A Group B Yes No Yes No Do you have a close friend 94.9 5.1 9.4 0.6 Have you visited a friend last week 93.4 6.6 7.5 2.5 Have you been accused of a crime last year 0 100 0.6 99.4 Have you been victim of physical violence last year 1.4 98.6 2.1 97.9

Univariate Prediction In both groups, IES is highly significantly correlated with both anxi-

ety and depression. The correlation coefficient between IES and anxiety is r=0.62 (p<.001) in group A, and 0.47 (p<.001) in group B. The coefficients for the correlation between IES and depression are 0.56 (p<.001) in group A and 0.46 (p<.001) in group B.

Table 3 shows bivariate correlations between IES score and satisfac-tion with life domains. All significant correlation coefficients are negative, indicating that a higher level of symptoms is associated with a lower SQOL. Table 3 also summarises partial correlations, i.e. the correlations between IES and SQOL scores with the common influence of anxiety and depression on both variables eliminated.

Table 3. Correlation coefficients and significance level for bivariate correlations and partial correlations-controlled for depression and anxiety from SCL-90R between IES and satisfaction with life domains MANSA (partial correlations were calculated only for the correlations that reached significance level in bivariate correlations)

Group A (N=139) Group B (N=474) Bivariate Partial Bivariate Partial correlations correlations correlations Correlations IES IES IES IES Life as a whole -.16 ns -.22*** -.05* Training/education -.11 ns -.15*** -.03 ns Finances -.10 ns -.05 ns Friendships -.16 ns -.13** -.03 ns Leisure activities -.10 ns -.13** .03 ns Accommodation -.02 ns -.09* -.04 ns Safety -.14 ns -.23*** -.16*** People living with -.16 ns -.15*** -.10* Sex life .04 ns -.14** -.02 ns Relationship with family -.25** -.17* -.14** -.07 ns Health -.29*** -.15 ns -.17*** -.03 ns Mental health -.42*** -.23** -.33*** -.14** Mean score -.26** -.07 ns -.30*** -.09*

Ns non significant * p<0.05 ** p<0.01 *** p<0.001


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When the influence of anxiety and depression is controlled for, most of the correlations fail to reach statistical significance. The only correlations of IES that remain significant are with satisfaction with relationship with family and mental health in group A, and with satisfaction with, people liv-ing with, safety, mental health and mean score in group B. Thus, satisfaction with mental health is the only SQOL life domain that remains significant in both groups of students when the influence of anxiety and depression is con-trolled for.

As far as objective indicators for quality of life shown in Table 2 are concerned, tests for an association with IES reveal only one significant find-ing: in group B, students that were victim of physical violence had higher IES scores (t=2.44, df=471, p<.05).

Discussion The association between posttraumatic stress and quality of life was

tested in two groups of students. The samples were relatively large, non-selective and homogeneous with respect to various factors such as age, edu-cational background and occupational status. Thus, there was no need to con-trol for the influence of these potentially confounding factors. Further meth-odological strengths of the study are that all subjects had been exposed to the same stressful events and that the time interval between events and assess-ment were consistent within each group.

The level of posttraumatic stress varied in both groups, and mean SQOL were similar to those found in other non-clinical samples [24]. Re-flecting their homogeneity in life circumstances, the samples show very lim-ited variance in objective quality of life indicators. Variables with so little variance are unlikely to be significantly correlated with other parameters. The only significant association we identified was a higher IES score in sub-jects who had been the victim of violence in the last year. The experience of violence may have caused posttraumatic stress alone or in combination with the effects of the stressful events during the air attacks. Some literature sug-gests that exposure to several traumatic events increases the probability of responding with posttraumatic stress symptoms [25].

In both groups, there were weak to moderate correlations between IES scores and SQOL ratings. Because of the bigger sample size, more of these correlation coefficients reached statistical significance in group B. The mean score of satisfaction ratings can be seen as the most reliable SQOL score [18]. It has been suggested that – unless there is a specific hypothesis related to a particular life domain – the mean score should be tested first. Only if there is a significant finding with respect to the mean score, results for single life domains should be analysed and interpreted. In both groups, the mean score is indeed significantly correlated with IES, and the coeffi-cients are of similar size. Associations are consistent, although the mean lev-


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els of posttraumatic stress differ between two groups for reasons that we cannot explore on the basis of data collected in the study.

The different period of time between stressful events and assessment, i.e. one year versus two years, appear not to have had a major impact on the association between posttraumatic stress and SQOL. This clear association, however, seems to be – mainly though not fully – mediated through symp-toms of anxiety and depression. Posttraumatic stress can be associated with mood and anxiety symptoms which are known to impact on SQOL ratings. The association of posttraumatic stress with subjects’ satisfaction with their mental health is the strongest one in bivariate tests, and the only one that re-mains statistically significant in both groups after controlling for mood and anxiety symptoms. It seems plausible that satisfaction with mental health may be more closely linked with posttraumatic stress symptoms than satis-faction with other life domains, and a stronger correlation is less likely to be explained by the influence of third factors as in this case mood and anxiety symptoms. Also, this association might be qualitatively different so that con-comitant mood and anxiety symptoms cannot fully explain it.

A shortcoming of the study design is the cross-sectional approach which does not allow conclusions to be drawn on causal relationships. Higher levels of posttraumatic stress might – mainly mediated through de-pression and anxiety – impact on SQOL, and, vice versa, lower SQOL might have had a negative influence on symptoms. Future prospective longitudinal research should address the issue of causality.

Conclusion The findings suggest that posttraumatic stress is associated with

SQOL in relatively homogeneous and non-selective groups of civilians who experienced stressful and potentially traumatic events. The results are rela-tively consistent in two independent but similar samples. Yet, they should be replicated in different groups and contexts.

It might be useful to assess quality of life indicators in future studies of samples suffering from posttraumatic stress. Such assessment may reveal that SQOL influences posttraumatic stress or is a relevant consequence of it, or both, and identify the role of mood symptoms in this association. In any case, symptoms of anxiety and depression need to be obtained and consid-ered as mediating factors. The nature of the relationship is not clear yet, and further systematic research applying quantitative and qualitative methods is required to understand the underlying processes. Intervention studies might explore whether therapeutic interventions should primarily aim to improve posttraumatic stress or mood symptoms to affect SQOL, or whether an im-proved SQOL will subsequently lead to reduced levels of anxiety, depression and posttraumatic stress.


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4. Mendlowicz M, Stein M. Quality of life in individuals with anxiety dis-orders. Am J of Psychiatry 2000; 157:669-682.

5. Dimenas ES, Dahlof CG, Jern SC, Wiklund IK. Defining quality of life in medicine. Scand J Prim Health Care 1990; 1:7-10.

6. Priebe S. Research in quality of life in mental health care: aims and strategies in quality of life and mental health care. In: Priebe S, Oliver J, Kaiser W (eds.) Quality of life and mental health care. Petersfield: Wrightson Biomedical Publishing Ltd; 1999. pp. 139-154.

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8. Pyne JM, Patterson TL, Kaplan, RM, Gillin, JC, Koch WL, Grant I. Assessment of the quality of life of patients with major depression. Psy-chiatr Serv 1997; 48: 224-230.

9. Kohen D, Burgess AP, Catalan J, Lant A. The role of anxiety and de-pression in quality of life and symptom reporting in people with diabe-tes mellitus. Qual of Life Res 1998; 7: 197-204.

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25. Follette VM, Polusny MA, Bechte AE, Naugle AE. Cumulative trauma: the impact of child sexual abuse, adult sexual assault and spouse abuse. J of Trauma Stress 1996; 9:257-262.

____________________________

Jelena JANKOVIĆ GAVRILOVIĆ, Odeljenje za socijalnu i komunalnu psi-hijatriju Barts i Medicinski fakultet Queen Mary u Londonu, London, Velika Britanija

Jelena JANKOVIC GAVRILOVIC, Unit for Social and Community Psy-chiatry, Barts and the London School of Medicine, Queen Mary, University of London, United Kingdom


Psihijat. dan. /2005/37/2/307-313/ Čavić T. Evaluacija grupne kognitivne psihoterapije posttraumatskog stresnog poremećaja

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Istraživački rad

UDK: 616.89 - 008.441 - 085.851

EVALUACIJA GRUPNE KOGNITIVNE PSIHOTERAPIJE POSTTRAUMATSKOG STRESNOG POREMEĆAJA

Tamara Čavić1, Mirko Pejović2

1Institut za neuropsihijatrijske bolesti “Dr Laza K. Lazarević”,

Beograd, Srbija i Crna Gora 2Institut za psihijatriju Kliničkog centra Srbije,

Beograd, Srbija i Crna Gora

Apstrakt: Ljudski odgovor na psihološku traumu jedan je od najvažnijih zdravstvenih problema današnjeg sveta. Lekovito dejstvo grupne kognitivne psihoterapije potvrđeno je u mno-gim istraživanjima. Cilj: ispitivanje mogućnosti primene metode kognitivnog restrukturisanja u grupi izbeglica sa iskustvom psihološke traume. Metod: rad se odvijao u srednjim grupama (15-18 članova), poluotvorenog tipa, sa dinamikom od dvadeset jednočasovnih nedeljnih seansi, tokom perioda od šest meseci. Pre i posle terapije primenjeni su sledeći instrumenti: Hamiltonove skale za procenu anksioznosti i depresivnosti (HAMA i HAMD) i revidirana Skala uticaja događaja (IES-R). Rezultati: grupna kognitivna psihoterapija ublažava anksioznost i depresivnost, redukuje simptome posttraumatskog stresnog poremećaja i pomaže u uspostavljanju kontrole nad trumat-skim iskustvom i modifikovanju maladaptivnih obrazaca ponašanja. Diskusija: postoji potreba za dugoročnim preventivnim programima namenjenim traumatizovanima koji bi uključivali i grupnu kognitivnu psihoterapiju.

Ključne reči: stres, trauma, grupa, kognitivna psihoterapija


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Uvod Ljudski odgovor na psihološku traumu jedan je od najvažnijih zdrav-

stvenih problema današnjeg sveta. Traumatizovane osobe često razvijaju posttraumatski stresni poremećaj (u daljem tekstu PTSP), poremećaj u kojem sećanje na traumatski događaj dominira svešću žrtava, osiromašujući životni smisao i zadovoljstvo. Osobe sa PTSP prepoznaju se po tome što su praktič-no “zaglavljene” u traumu, jer nastavljaju da ponovno proživljavaju misli, slike i osećanja originalnog događaja. Onog momenta kada intruzije (name-tanja) postanu dominantne, traumatizovana osoba svoj život počinje da orga-nizuje oko različitih načina izbegavanja [1]. Svesni svojih poteškoća da kon-trolišu emocije, traumatizovani troše energiju na izbegavanje uznemirujućih unutrašnjih senzacija, umesto da odgovaraju na zahteve sredine. Tako, oni gube zadovoljstvo u stvarima koje su ih ranije radovale i osećaju se “kao da su mrtvi”. Ova otupelost može se manifestovati kao depresija, anhedonija i manjak motivacije, kao psihosomatska reakcija ili disocijativno stanje. Ova pojava tokom psihoterapije sprečava osobu da zamisli sebe u budućnosti.

Kognitivna psihoterapija Većina kognitivnih psihoterapija visoko je kompatibilna sa teorijom

stresa Zeligmana i Pitersona [2]. Kognitivno restrukturisanje je tehnika kogniti-vne terapije koja omogućava osobi da identifikuje negativna, iracionalna uvere-nja i zameni ih istinitim, racionalnim stavovima. Veći deo teorije kognitivnog restrukturisanja [3] derivat je Elisove racionalno emotivne terapije – RET. Ona ima svoje specifičnosti: 1) zasnovana je na koherentnom kognitivnom modelu, 2) zasnovana je na otvorenoj terapijskoj saradnji, gde se pacijent posmatra kao ravnopravan partner u timskom rešavanju problema, 3) kratka je i vremenski ograničena, 4) strukturisana je i direktivna, 5) orijentisana na problem i usmere-na na činioce koji održavaju poteškoće, 6) oslanja se na proces ispitivanja i “vo-đenog otkrivanja“, a ne na ubeđivanje, pridike ili polemiku, 7) bazirana je na induktivnim metodama, tako da pacijent nauči da uviđa misli i uverenja čija se istinitost testira i 8) edukativna je, jer predstavlja kognitivne tehnike kao veštine koje se osvajaju vežbanjem. Ključni element u ovom pristupu jeste ideja o kon-tranapadu, odnosno, zameni iracionalnih uverenja potpuno suprotnim racional-nim uverenjima. Terapeut upoznaje pacijente sa činjenicom da su mnoge misli koje stvaraju probleme u suštini iracionalne ili pogrešne. Pacijenti se podstiču da daju svoje predloge koji su načini da se takva uverenja promene. To može biti: nova korisna informacija, polemika o problemu, nalaženje nelogičnosti ili ne-konzistentnosti takvih stavova, nalaženje istomišljenika u osobi od autoriteta, ponavljanje alternativnog uverenja i njegova provera u konkretnim situacijama. Kontranapad sadrži sve to. To su stavovi koji će inhibirati prvobitna negativna uverenja i, konačno, zameniti ih. Prema tome, kontranapad deluje poput uvođe-nja nove veštine, ili boljeg načina da se neka veština izvede. Najpre se menja način obavljanja radnje, a zatim, nakon vežbanja, ona postaje automatska. U ka-snijem sledu treba pronaći kontraudarce za sva negativna uverenja i upotrebiti ih [4].


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Grupa Emocionalno vezivanje prva je spontana zaštita od traumatizacije.

Svaka dobro integrisana, kohezivna grupa predstavlja snažnu odbranu od ne-gativnih osećanja. Bez obzira na prirodu traume ili strukturu grupe, cilj grup-ne terapije je pomoć ljudima da aktivno prate zahteve trenutka, bez intruzija proteklih iskustava. Grupna terapija posmatra se kao metoda izbora za paci-jente sa traumatičnim iskustvom. Bila je korišćena za žrtve nasilja, prirodnih katastrofa, seksualnog zlostavljanja u detinjstvu, silovanja, bračnog nasilja, koncentracionih logora i ratne traume [5]. Zadatak grupne intervencije jeste da žrtve ponovo zadobiju osećanje sigurnosti i kontrole. Karakteristika i ovih grupa jeste slobodna razmena informacija i suočavanje sa realnošću. Članovi grupe se postepeno ohrabruju da tolerišu anksioznost, a ne da beže od nje. Na taj način stiču samopouzdanje i napuštaju defanzivnu poziciju. Iako različiti, pacijenti se okupljaju oko sličnosti vezanih za traumu, što ih otvara jedne prema drugima da slobodno govore o svojim strahovima, gubicima i moguć-nostima nalaženja novih razloga za život i optimizam. Grupa je najpogodnije okruženje koje može da drži i apsorbuje veliku količinu agresije i depresije. Ona je posebno korisna za savladavanje traumatskih događaja. Najpre, u grupi klijent ima osećaj univerzalnosti, shvatajući da nije sam u svojoj patnji. Dalje, grupa obezbeđuje delegirano učenje slušanjem kako drugi ljudi reša-vaju probleme. Učestvovanjem u grupi svaki pacijent prvi put se javno oba-vezuje na promenu. Grupa je prilika da se dobije pomoć u borbi sa iracional-nim mislima. Cilj borbe sa iracionalnim mislima je da se alogične i maladap-tivne misli zamene pozitivnim i logičnim.

Ciljevi Osnovni cilj ovog istraživanja bio je ispitivanje mogućnosti primene

metode kognitivnog restrukturisanja u grupi izbeglica sa iskustvom psihološ-ke traume. U sklopu navedenog postavljeni su sledeći terapijski ciljevi: ubla-žavanje anksioznosti i depresivnosti, redukcija posttraumatskih simptoma, kognitivna korekcija traumatskog materijala, katarza, emocionalna prorada sadržaja, uspostavljanje kontrole nad traumatskim iskustvom, kognitivna sa-moregulacija i osvajanje novih adaptivnih strategija za savladavanje traume.

Metod U istraživanje je uključeno sedamdeset osoba. Kriterijumi za ulazak

u istraživanje bili su: izbegličko iskustvo, minimum osamnaest godina staros-ti, motivisanost za ulazak u terapiju, prisustvo psihičkih, interpersonalnih ili telesnih problema i odsustvo prethodne psihijatrijske dijagnoze. Prva faza rada sastojala se iz upoznavanja, stvaranja osnovnog poverenja i kliničkog intervjua. Cilj pregleda bio je: a) utvrđivanje kriterijuma za uključivanje u uzorak, i b) procena psihičkog statusa ispitanika. Druga faza sastojala se u popunjavanju baterije upitnika. Treća faza odvijala se kroz grupni rad. Krite-rijumi za uključivanje u grupnu terapiju bili su sledeći: 1) uključujući: moti-


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vacija za promenu, zajednički zadaci i ciljevi i 2) isključujući: nesposobnost prihvatanja grupnog setinga i normi ponašanja. Najzad, četvrta faza istraži-vanja obuhvatila je zatvaranje grupa i retest istim instrumentarijumom.

Korišćeni su sledeći instrumenti: Hamiltonova skala za procenu dep-resivnosti [6], Hamiltonova skala za procenu anksioznosti [7] i Horowitz-ova revidirana Skala uticaja događaja [8].

Kognitivno restrukturisanje odvijalo se kroz rad u srednjim grupama, poluotvorenog tipa, sa po 15-18 članova. Grupe su se sastajale jednom ne-deljno u trajanju od jednog sata. U periodu od šest meseci održano je dvade-set seansi. Postupak je obuhvatio nekoliko faza: procena specifičnih traumat-skih sećanja, kognitivno restrukturisanje specifičnih sećanja, procena stavova grupe prema svetu uopšte i, najzad, restrukturisanje stavova grupe prema svetu. Tokom čitavog procesa aktivno se koristila intervencija “kontrana-pad”, koja ima krucijalnu ulogu i u radu na problemima adaptacije. “Kontra-napad” se koristio u skladu sa svojim osnovnim karakteristikama: direktno suprotan pogrešnom uverenju, sadrži uverljivu realnu tvrdnju, pacijent treba da sam da osmisli što je moguće više kontraudaraca, mora da potiče od paci-jenta, a ne od terapeuta, mora biti koncizan, mora biti izrečen samouvereno, agresivno i/ili emotivno i, mora biti intenzivan.

Rezultati Anksioznost Pregled učestalosti pojedinih simptoma na Hamiltonovoj skali anksi-

oznosti (HAM-A) pokazuje da su pre lečenja u ukupnom uzorku najsnažnije bili izraženi simptomi anksioznog i depresivnog raspoloženja, napetosti, ne-sanice, kognitivnih smetnji i motornog nemira (p=0.000). Anksioznost nakon terapije opada u ukupnom uzorku i na svakom pojedinom ajtemu. Treći aj-tem na Hamiltonovoj skali anksioznosti (strahovi) pokazuje slabije poboljša-nje u odnosu na ostale, gde se poboljšanje kreće od 55-58%. Ukupan skor anksioznosti na Hamiltonovom testu pre terapije iznosio je X =29.3, SD=9.1, dok nakon terapije iznosi X =11.0, SD=9.9. p=0.000 (Grafikon 1).

Grafikon 1. Dejstva terapije prema nivou anksioznosti

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Depresivnost Pre tretmana depresivnost se dominantno ispoljavala strepnjom, dep-

resivnim raspoloženjem, samooptuživanjem, ranom insomnijom, gubitkom interesovanja, psihomotornom usporenošću, lošom koncentracijom, varijaci-jama raspoloženja, uz dobar uvid u problem (p=0.000). I pored visoke depre-sivnosti ispitanici nisu pokazali suicidalnost ni pre, ni posle terapije. Pre te-rapije ukupan uzorak (97%) pokazivao je umerenu do izraženu depresivnost (HAMD test X =30.8, SD=9.4). Nakon kognitivnog restrukturisanja opada intenzitet kako kod svakog pojedinog simptoma, tako i u ukupnom skoru (HAMD retest X =12.6, SD=10.9, p=0.000). Izrazito depresivnih bilo je 37.1% (skor preko 15), blago depresivnih 15.1% (skor 8-15), dok 47.1% ispi-tanika nije pokazalo znake depresivnosti. Razlike u vrednostima postoje za sve pomenute simptome i one su visoko statistički značajne, osim na ajtemi-ma suicidalnost, depersonalizacija i derealizacija, paranoidnost i opsesivno-kompulzivni simptomi, koji su nisko ocenjeni i pre i posle terapije. Posle le-čenja vrednosti depresivnosti značajno opadaju i dobijaju klinički blagu for-mu (Grafikon 2). Grafikon 2. Dejstvo terapije prema nivou depresivnosti

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simptomi izbegavanja nešto izraženiji u odnosu na simptome nametanja. Po-ređenjem srednjih vrednosti ukupnog skora i pojedinih klastera (IES-R) uoča-va se poboljšanje nakon kognitivne grupne psihoterapije (Tabela 1). Tabela 1. Simptomi PTSP na IES-R pre i posle terapije

Pre terapije Posle terapije p IES-ukupan 30.36 (SD=11.23) 18.47 (SD=12.45) 0.001 IES-nametanje 14.74 (SD=5.35) 8.64 (SD=6.23) 0.001 IES-izbegavanje 15.59 (SD=6.30) 9.83 (SD=6.72) 0.001


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Ispitanici su pre početka terapije kao najčešće navodili simptome sa ajtema 14 (“sve što me podseća na taj događaj ponovo mi vraća osećanja ve-zana za događaj”), 13 (“pokušao sam da ne mislim o tome”), 10 (“te slike se same javljaju i kad mislim o nečem drugom”), 17 (“ako počnem da pričam o tome učini mi se kao da se sve ponovo događa”), 2 (“izbegavao sam da se uznemirim kad bih o tome mislio ili bi me nešto podsetilo na to”) i 3 (“poku-šao sam da to izbacim iz sećanja”). Simptomi koji opisuju kognitivne smet-nje imali su kontinuirano niske vrednosti (26 – “ljudi mi kažu da sam rase-jan”, 27 – “događa mi se da izađem iz kuće, a da zaboravim da obučem neki deo odeće”, 28 – “ponekad se toliko zanesem da ne vidim šta se oko mene događa”). Ovo govori o relativnoj očuvanosti kognitivnih funkcija, pažnje i koncentracije kod naših ispitanika sa PTSP (Grafikon 3).

Grafikon 3. Distribucija simptoma PTSP prema srednjim vrednostima pre terapije

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Iz Grafikona 4. uočava se značajno poboljšanje PTSP simptoma pos-

le terapije, gledano prema srednjim vrednostima, pri čemu ono izostaje samo kod ajtema 6 (“sanjao sam ono što se dogodilo”) i ajtema 3 (“pokušao sam da to izbacim iz sećanja”). Grafikon 4. Distribucija simptoma PTSP prema srednjoj vrednosti posle terapije

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Značajnost razlika simptoma PTSP pre i posle terapije nalazimo na većini ajtema. Ipak, određeni simptomi ne menjaju se značajno nabolje, kao npr. na ajtemu 6, 15 (snovi o događaju, “zaleđena” osećanja) i 26, 27, 28 (očuvanost pažnje i koncentracije) (Tabela 2).

Tabela 2. Statistička značajnost razlika simptoma PTSP (IES-R) pre i posle terapije

Diskusija U ovom istraživanju izbeglice su imale značajnu stopu posttraumat-

skog stresnog poremećaja, anksioznosti i depresivnosti, što je u skladu sa nalazima iz literature. Naši ispitanici, međutim, nisu pokazali značajan nivo suicidalnosti i pored teških traumatskih iskustava i uslova života. Posttrau-matski stresni poremećaj manifestovao se dominantno simptomima iz pod-grupa nametanja i izbegavanja, dok su simptomi povećane uzbuđenosti bili manje prisutni, što je u skladu sa nalazima ranijih sličnih istraživanja [9,10]. Lekoviti efekti grupne kognitivne psihoterapije potvrđeni su u mnogim istra-živanjima: žrtava torture, u procesu prorade traumatskog materijala u tugo-vanju i u prevenciji hronifikacije PTSP [11,12]. Naše istraživanje potvrdilo je hipotezu da metoda grupne kognitivne psihoterapije ublažava anksioznost, depresivnost i redukuje simptome posttraumatskog stresnog poremećaja, da pomaže u uspostavljanju kontrole nad traumatskim iskustvom i modifikuje maladaptivne obrasce ponašanja. Postoji potreba za dugoročnim preventiv-nim programima namenjenim traumatizovanima koji bi uključivali i grupnu kognitivnu psihoterapiju.

Ajtemi Z p

IESRR1 – IESRT1 -5.631 .000IESRR2 – IESRT2 -5.333 .000IESRR3 – IESRT3 -3.573 .000IESRR4 – IESRT4 -4.506 .000IESRR5 – IESRT5 -4.114 .000IESRR6 – IESRT6 -1.496 .135IESRR7 – IESRT7 -3.170 .002IESRR8 – IESRT8 -3.512 .000IESRR9 – IESRT9 -3.955 .000IESRR10 – IESRT10 -5.129 .000IESRR11 – IESRT11 -4.244 .000IESRR12 – IESRT12 -3.614 .000IESRR13 – IESRT13 -4.893 .000IESRR14 – IESRT14 -5.388 .000IESRR15 – IESRT15 -2.951 .003IESRR16 – IESRT16 -2.840 .005IESRR17 – IESRT17 -5.134 .000IESRR18 – IESRT18 -4.904 .000IESRR19 – IESRT19 -2.972 .003IESRR20 – IESRT20 -3.052 .002IESRR21 – IESRT21 -4.287 .000IESRR22 – IESRT22 -4.767 .000IESRR23 – IESRT23 -3.447 .001IESRR24 – IESRT24 -3.356 .001IESRR25 – IESRT25 -2.864 .004IESRR26 – IESRT26 -2.402 .016IESRR27 – IESRT27 -2.523 .012

Psihijat. dan. /2005/37/2/315-322/ Cavic T. Evaluation of group cognitive psychotherapy of post-traumatic stress disorder

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Research article

UDK: 616.89 - 008.441 - 085.851

EVALUATION OF GROUP COGNITIVE PSYCHOTHERAPY OF POST-TRAUMATIC STRESS DISORDER

Tamara Cavic1, Mirko Pejovic2

1Institute of Neuropsychiatric Disorders “Dr Laza K. Lazarevic”, Belgrade, Serbia and Montenegro

2Institute od Psychiatry, Clinical Centre of Serbia, Belgrade, Serbia and Montenegro

Abstract: Human response to psychological trauma is one of the most important health problems today. Healing effects of group cognitive psychotherapy were confirmed in many stud-ies. Aim: evaluation of cognitive restructuring in the group of refugees with psychological trauma. Method: work was conveyed in semi-open median groups (15-18 members), with a dynamics of 20 one-hour weekly sessions during a period of 6 months. Before and after therapy the following instruments were applied: Hamilton Scales for anxiety and depression (HAMA and HAMD) and Impact Event Scale-revised (IES-R). Results: group cognitive psychotherapy alleviates anxiety and depression, reduces symptoms of post-traumatic stress disorder and helps in regaining control over traumatic experiences and modifying maladaptive patterns. Discussion: There is a need for long-term preventive programs for traumatized people which would include group cognitive psycho-therapy.

Key words: stress, trauma, group, cognitive psychotherapy


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Introduction Human response to psychological trauma is one of the most impor-

tant health problems today. Traumatized people often develop post-traumatic stress disorder (PTSD), disorder in which a memory of traumatic event dominates over consciousness of victims, empowering life meaning and joy. Persons with PTSD can be recognized by being practically “trapped” in trauma, because they continue to re-experience thoughts, images and memo-ries of the original event. The moment intrusions become dominant, trauma-tized individual begin to organize his life around different ways of avoidance [1]. Aware of their difficulties to control emotions, traumatized invest energy in avoidance of internal distressing sensations, instead of responding to re-quests of the environment. Thus, they loose pleasure in things they enjoyed before and feel “like dead”. Such numbing can be manifested as depression, anhedonia and lack of motivation, as psychosomatic reaction and dissociative state. This phenomenon disables individual for future projection.

Cognitive psychotherapy Most of cognitive psychotherapies are highly compatible with stress

theory of Seligman and Peterson [2]. Cognitive restructuring is a technique of cognitive therapy that enables a person to identify negative, irrational thoughts and replace them with true, rational states. Most of theories of cognitive restructuring [3] are derived from Ellis’s Rational Emotional Therapy – RET. It has it’s specific features: 1) based on coherent cognitive model, 2) based on open therapeutic alliance, where patient is recognized as an equal partner in problems solving team, 3) brief and time-limited, 4) structured and directive, 5) problem-oriented and focused on factors that maintain difficulties, 6) re-lied on the process of questioning and “guided disclosure”, not on persua-sion, preaching and polemics, 7) based on inductive methods, so patient can learn to catch thoughts and attitudes and tests their truthfulness and 8) educa-tional, presents cognitive techniques as a skills that can be conquered by practice. Key element in this approach is an idea of counterattack i.e. re-placement of irrational beliefs with direct contradictory rational beliefs. Therapist introduces to clients the fact that many thoughts that are causing problems are, in fact, irrational and wrong. Clients are animated to give their suggestions what are the ways to change such beliefs. It can be: new useful information, polemics on problem, finding irrationality and inconsistency in such states, finding follower in person of authority, repeating of alternate be-lief and it’s checking in concrete situations. Counter attack contains it all. Those are attitudes that will inhibit previous negative beliefs and, finally, replace them. So, counterattack acts like implementation of a new skill or better way to perform some skill. First it changes a ways how an action is performed and then, after practice, it becomes automatic. In later sequence counters for all negative thoughts need to be found and used [4].


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Group Emotional bonding is the first spontaneous protection against trauma-

tization. Every well integrated, cohesive group is a strong defense against negative feelings. No matter of the nature of trauma or structure of the group, the aim of group therapy is to help people to follow actively current requests, without intrusions of past experiences. Group therapy is a method of choice for patients with traumatic experiences. It was used for victims of interper-sonal violence, natural catastrophes, sexual abuse in childhood, rape, marital violence, concentration camps and war trauma [5]. Task of the group inter-vention in victims is to regain feeling of safety and control. Characteristics of these groups are free exchange of information and facing the reality. Group members are encouraged to tolerate anxiety and not run away from it. In that way they achieve self-esteem and abandon defensive position. Although dif-ferent, patients gather around similarities related to trauma which opens them one to another to speak freely about their fears, loses and possibilities of finding new reasons for life and optimism. Group is the most convenient en-vironment that can keep and absorb large amount of aggression and depres-sion. Group is especially useful for abreaction of traumatic events. There are many advantages of group cognitive psychotherapy. First, in the group client has a sense of universality, realizing he is not alone in his sorrow. Further, group provides delegated learning by listening how other people handle their problems. By participating the group client for the first time obliges to chan-ge in public. Group is an opportunity to get help in the battle with irrational thoughts. The aim of the fight with irrational thoughts is to replace illogical and maladaptive thoughts with positive and logical ones.

Aims The main aim of this research was to investigate the possibility of

application of cognitive restructuring method in the refugees with psycho-logical trauma. In that sense, the following therapeutic aims are posed: ame-liorating of anxiety and depression, reduction od post-traumatic symptoms, cognitive correction of traumatic material, catharsis, emotional working-through, taking control over traumatic experience, cognitive self-regulation and obtaining new adaptive coping strategies.

Method Seventy people were included into study. Criteria for entering the

study were: refugee experience, minimum 18 years of age, motivation for therapy, presence of psychical, interpersonal or somatic problems, and ab-sence of previous psychiatric diagnosis. First phase consisted of acquaint-ance, formation of basic trust and clinical interview. The aim of the check-up was: a) to ascertain including criteria and b) assess psychical status of ex-aminees. Second phase was application of instruments. Third phase was con-veyed through group work. Criteria for entering group therapy were: 1) in-


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cluding: motivation for change, common tasks and aims, and 2) excluding: incapability to accept group setting and norms of behavior.

The following instruments were used: Hamilton Rating Scale for De-pression [6], Hamilton Rating Scale for Anxiety [7] and Horowitz Impact of Event Scale – Revised [8].

Cognitive restructuring was conveyed through the work in semi-opened median groups with 15-18 members. Groups used to meet once a week for one hour. During six months twenty sessions were held. Procedure included several steps: assessment of specific traumatic memories, cognitive restructuring of specific memories, assessment of group members attitudes towards the world in general and, finally, restructuring of group’s attitudes towards the world. All along this process the intervention “counterattack” was used, that has crucial role in the work with adjustment problems, too. “Counterattack” was used in accordance with it’s basic characteristics: di-rectly opposite to wrong belief, contains assuring realistic state, client has to create as much as possible more counterattacks, it has to come from the cli-ent and not from the therapist, has to be concise, has to be said with self-confidence, aggressively and/or emotionally and, has to be intensive.

Results Anxiety Review of symptoms frequencies on HAM-A show that the most

prominent before treatment were symptoms of anxiety and depressive mood, nervousness, cognitive impairment and motor agitation (p=0.000). After treatment anxiety decreases in total sample, as well as on each item. Item 3 (fears) shows less improvement comparing with others, where it ranges 55-58%. Total score on HAMA test was X =29.3, SD=9.1, while on HAMA retest was X =11.0, SD=9.9. p=0.000 (Fig. 1).

Fig. 1. Effects of therapy by level of anxiety (p=0.000)

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Depression Before treatment depression was manifested with anxiety, depressive

mood, self-accusation, early insomnia, loss of interest, psychomotor retarda-tion, poor concentration, mood variations and good insight (p=0.000). Al-though highly depressed, examinees did not show suicidality both before and after therapy. Before therapy total sample (97%) showed moderate to severe depression (HAMD test X =30.8, SD=9.4). After cognitive restructuring in-tensity decreases on each symptom, and in total score (HAMD retest X =12.6, SD=10.9, p=0.000). There was 37.1% of severely depressed (score over 15), 15.1% with mild depression (score 8-15), while 47.1% examinees did not manifest signs of depression. There are statistically significant differ-ences for all symptoms, except on items for suicidality, depersonalization and derealization, paranoid thoughts and obsessive-compulsive behavior, which were low both before and after the treatment. After the therapy values of depression decreased significantly and took a mild clinical form (Fig. 2). Fig. 2. Effects of therapy by level of depression (p=0.000)

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PTSD Looking at the IES-R frequencies, one can notice that before therapy

avoiding symptoms were slightly more expressed that intrusive symptoms. Comparing the medians of total score and both clusters (IES-R) we can see improvement after group cognitive psychotherapy (Table 1).

Table 1. Symptoms of PTSD on IES-R before and after therapy

Before therapy After therapy p (IES-total) 30.36 (SD=11.23) 18.47 (SD=12.45) 0.001 (IES-intrusion) 14.74 (SD=5.35) 8.64 (SD=6.23) 0.001 (IES-avoidance) 15.59 (SD=6.30) 9.83 (SD=6.72) 0.001


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Before therapy examinees most frequently referred symptoms from the items 14 (“everything that reminds me of that event brings me back feel-ing about it”), 13 (“I tried not to thing of that”), 10 (“that images appears event when I think of something else”), 17 (“if I start talking of that it looks like it happens again”), 2 (“I avoided to be disturbed when thinking or being reminded of that”) and 3 (“I tried to through it away from my mind“). Symp-toms of cognitive impairment had continually low values (26 – “people say I am distracted”, 27 – “it happens to me to leave home, forgetting to put some clothes on”, 28 – “sometimes I drift away and don’t see what happens around me”). This can be in favor of relative preservation of cognitive functions, attention and concentration in examinees with PTSD (Fig. 3). Fig. 3. Distribution of PTSD symptoms by medians before therapy

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apy, according to medians, on Fig. 4, except on the item 6 (“I dreamt of what happened”) and item 3 (“I tried to through it away from my memory”). Fig. 4. Distribution of PTSD symptoms by median after therapy

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Significant differences between symptoms of PTSD before and after therapy can be found on the majority of items. Some of them, however, did not change, i.e. on items 6, 15 (dreams of event, numbed feelings) and 26, 27, 28 (preserved attention and concentration) (Table 2). Table 2. Statistical significance of PTSD symptoms (IES-R) before and after therapy

Discussion Refugees in this study manifested significant rate of post-traumatic

stress disorder, anxiety and depression, which is in accordance with findings from the literature. Our examinees did not show significant level of suicidal-ity, no matter of severe traumatic experiences and living conditions. Post-traumatic stress disorder was presented predominantly with symptoms from the clusters intrusion and avoidance, while the symptoms of hyperarousal were less notable, which corresponds with findings of previous similar stud-ies [9,10]. Healing effects of group cognitive psychotherapy were confirmed

Items Z pIESRR1 – IESRT1 -5.631 .000IESRR2 – IESRT2 -5.333 .000IESRR3 – IESRT3 -3.573 .000IESRR4 – IESRT4 -4.506 .000IESRR5 – IESRT5 -4.114 .000IESRR6 – IESRT6 -1.496 .135IESRR7 – IESRT7 -3.170 .002IESRR8 – IESRT8 -3.512 .000IESRR9 – IESRT9 -3.955 .000IESRR10 – IESRT10 -5.129 .000IESRR11 – IESRT11 -4.244 .000IESRR12 – IESRT12 -3.614 .000IESRR13 – IESRT13 -4.893 .000IESRR14 – IESRT14 -5.388 .000IESRR15 – IESRT15 -2.951 .003IESRR16 – IESRT16 -2.840 .005IESRR17 – IESRT17 -5.134 .000IESRR18 – IESRT18 -4.904 .000IESRR19 – IESRT19 -2.972 .003IESRR20 – IESRT20 -3.052 .002IESRR21 – IESRT21 -4.287 .000IESRR22 – IESRT22 -4.767 .000IESRR23 – IESRT23 -3.447 .001IESRR24 – IESRT24 -3.356 .001IESRR25 – IESRT25 -2.864 .004IESRR26 – IESRT26 -2.402 .016IESRR27 – IESRT27 -2.523 .012


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in many studies: of torture victims, in the process of working-through of traumatic material in mourning and in prevention PTSD chronification [11,12]. This research confirmed a hypothesis that a group cognitive psycho-therapy method ameliorates anxiety and depression, reduces symptoms of PTSD, helps in regaining control over traumatic experience and modify mal-adaptive patterns of behavior. There is a need for a long-term preventive program for traumatized people, which would include group cognitive ther-apy, too.

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periencing in expert psychodynamic-interpersonal and cognitive-behavioural therapies. J Consult Clin Psychol 1998, 66(4): 634-40.

10. Wolfe J, Keane TM, Kaploupek DG, Mora CA, Wine P. Patterns of posi-tive readjustment in Vietnam combat veterans. J Traum Stress 1993, 6:179-93.

11. Emmelkamp J, Komproe IH, Van Ommeren M, Schagen S. The relation between coping, social support and psychological and somatic symptoms among torture survivors in Nepal. Psych Med 2002, 32: 1465-70.

12. Kramer S, Akhtar S. When the body speaks: psychological meanings in ki-netic clues. New Jersey: Jason Aronson Inc; 1992.

__________________________ Dr Tamara ČAVIĆ, dr sc med, psihijatar, Institut za neuropsihijatrijske bolesti “Dr Laza Lazarević”, Beograd, Srbija i Crna Gora

Tamara CAVIC, MD, PhD, psychiatrist, Institute of Neuropsychiatric Dis-orders “Dr Laza K. Lazarevic”, Belgrade, Serbia and Montenegro


Psihijat. dan. /2005/37/2/323-327/ Kontaksakis P. V. Likantropija u radovima vizantijskih lekara

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Stručni rad

UDK: 616. 89 - 008 (495.02) 616. 89 (091)

LIKANTROPIJA U RADOVIMA VIZANTIJSKIH LEKARA Vasilis P. Kontaksakis1, †Džon G. Laskaratos2, Panajotis P. Ferentinos1,

Maria-Irini V. Kontaksaki1, Džordž N. Hristodulu1

1Katedra za psihijatriju, Univerzitet u Atini, Grčka 2Istorija medicine, Univerzitet u Atini, Grčka

Apstrakt: Svrha ovog rada je da napravi pregled tekstova o likantropiji iz vizantijske medicinske literature i da proceni njihov uticaj na medicinu od tog perioda do danas. Proučavani su originalni tekstovi na grčkom jeziku vizantijskih lekara, kao što su Oribasije (IV vek n.e.), Ecije (VI vek n.e.), Pavle Eginjanin (VII vek n.e.), Pavle iz Nikeje (VII vek n.e.), Mihajlo Psel (XI vek n.e.) i Jovan Aktuarije (XIV vek n.e.). Autori su, takođe, pregledali i sačuvane tekstove antičkih grčkih i rimskih lekara. Vizantijski lekari su pružili detaljne opise kliničke slike likantropije, kao i predloge za njeno lečenje. Smatrali su da likantropija predstavlja oblik melanholične ili psihotične depresije, a ne da je demonskog porekla, što je u skladu sa mišljenjem rimskog lekara Marsilija Siditskog (II vek n.e.), koji je prvi opisao ovaj sindrom. Stavovi vizantijskih lekara o likantropiji su neposredno ili posredno uticali na način na koji se arapska ili zapadnoevropska medicina kasni-je bavila tim problemom.

Ključne reči: vizantijska medicina, istorija medicine, likantropija, depresija, melanholi-ja, psihoza


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Uvod Likantropija je sumanuto uverenje bolesnika da se preobražava u ži-

votinju, po tradiciji, u vuka [1,2]. Termin je nastao od grčkih reči lycos = vuk i anthropos = čovek. Najraniji opisi ovog sindroma mogu se naći u grčkoj mitologiji. Poluboga Likaona Zevs je za kaznu pretvorio u vuka, jer je poku-šao da posluži Zevsa mesom žrtvovanog mladića [3]. Jedan kasniji opis ovog sindroma nalazi se i u Bibliji. U Prvoj knjizi Danilovoj, Bog je kaznio vavi-lonskog kralja Nabukodonosora tako što ga je na sedam godina pretvorio u vola [4,5].

Početkom XIX veka likantropija je smatrana duševnim poremećajem [6]. U svetskoj literaturi je tokom XX veka objavljeno nekoliko prikaza slu-čajeva likantropije. Većina se odnosila na pacijente koji su patili od afektiv-nih ili psihotičnih poremećaja. Ostali slučajevi preobražaja čoveka u životi-nju javili su se kod pacijenata sa drugim mentalnim poremećajima, među ko-jima su bili poremećaji ličnosti, histerija, zloupotreba alkohola ili droga, or-ganski moždani sindromi, demencija i epilepsija [7-11].

Ovaj rad ima za cilj da pokaže da su radovi vizantijskih lekara o li-kantropiji obezbedili nove podatke i ponudili jasnija tumačenja ovog stanja; štaviše, oni pružaju dokaze da je likantropija od antičkih vremena smatrana duševnom bolešću.

Vizantijska medicina, u stvari, predstavlja nastavak antičke grčke, helenističke i rimske tradicije u medicini, kao i važnu kariku koja je povezuje sa zapadnoevropskom medicinom na koju je uticala neposredno ili posredno, preko tekstova arapskih lekara. Proučavanje tekstova vizantijskih lekara je od velikog značaja jer većina njih reprodukuje suštinu radova starogrčkih lekara, od kojih je veći deo danas izgubljen, a u isto vreme, daje i svoj lični doprinos temi [12]. Veliki vizantijski doktori, od Posejdonija i Oribasija (IV vek n.e.) do Jovana Aktuarija (XIV vek n.e.), ostavili su za sobom mnoštvo kliničkih opisa od značaja za psihijatriju, koje su preuzeli iz dela antičkih lekara, po-sebno Hipokrata (V vek p.n.e.), Galena (II vek n.e.), Areteja (I-II vek n.e.), Sorana iz Efesa (I-II vek n.e.) i drugih. U njihovim delima je, osim likantro-pije, opisan i veliki broj drugih mentalnih poremećaja, kao što su manija, me-lanholija, katafora (duboka depresija), frenitis, ljubavna bolest, inkubus (no-ćna mora), letargija, nesanica, senilna atrofija mozga (vrsta demencije), tro-vanje alkoholom i epilepsija [13].

Materijal Prvi vizantijski lekar koji se bavio likantropijom nije bio Ecije, kako

tvrde neki autori [14], već Oribasije (IV vek n.e.), koji je napisao prvo po-glavlje u vizantijskoj medicinskoj literaturi na ovu temu, pod naslovom “O likantropiji” [15]. Oribasije je pisao da likantropi izlaze noću, uglavnom se zadržavaju u blizini grobnica do zore, a njihovo ponašanje je nalik vučjem. Ovakvi bolesnici su mogli da se prepoznaju uz pomoć sledećih znaka i simp-toma: bledi su, pogled im je prazan, oči suve i duboko usađene i bez suza.


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Jezik im je suv i ne mogu da luče pljuvačku. Uvek su žedni, a potkolenice su im obično povređene jer se često sapliću o stvari. Prema Oribasiju, ova bolest je dijagnostikovana kao vrsta melanholije. Lečenje u toku hronične faze je uključivalo smirivanje pacijenta, dugotrajno puštanje krvi dok bolesnik ne bi izgubio svest, kupanje u svežoj (ne i morskoj) vodi, a preporučivalo se uno-šenje tečnosti. Nakon toga, pacijent je tokom tri dana morao da se pridržava ishrane zasnovane na obranom mleku i da uzima biljni purgativ šućur, što je ponavljano tri puta (ukupno devet dana). Korišćeno je i bilje pomešano sa medom, što je u to vreme bio uobičajen lek za melanholiju. U akutnoj fazi bolesti, u uši i nozdrve bolesnika ukapavana su uspavljujuća ulja koja su naj-češće sadržavala opijum.

Još jedan čuveni vizantijski lekar bavio se likantropijom – Ecije (VI vek n.e.), koji je napisao poglavlje pod naslovom “O likantropiji, odnosno kinantropiji, prema Marsiliju” [16], opisao je ponašanje bolesnika na isti na-čin kao Oribasije, dodavši da likantropi lutaju noću u februaru, oponašajući vukove ili pse. Dao je istu kliničku sliku kao Oribasije, dodajući da su rane na potkolenicama nastale kao rezultat čestih padova i ujeda pasa, i da se ne mogu zalečiti. On je, takođe, smatrao da je ova bolest jedan oblik melanholi-je i predlagao je sličan način lečenja kao Oribasije. Pridodao je neke nove purgative, kao što su “sveti lekovi” Rufusa, Arhigena i Justusa. Neposredno pre večernje krize, on je, takođe, preporučivao uspavljujuće i slične supstan-ce, posebno opijum, koji se davao ili u obliku ulja kroz nozdrve, ili u nekim retkim slučajevima per os.

Pavle Eginjanin (VII vek n.e.) bio je saglasan sa dva prethodna auto-ra. Jedno značajno poglavlje koje je napisao naslovio je “O likantropiji ili Likaonu”, što je sa sobom nosilo konotacije inspirisane grčkom mitologijom [17].

Anonimni pisac [18] jednog poglavlja o likantropiji slagao se sa sta-vovima Oribasija i Ecija, i dodao da su likantropi neuobičajeno mršavi, što je karakteristično za melanholiju. Njihova melanholična konstitucija je ili uro-đena ili stečena, nastala kao posledica nesanice, stresnih životnih situacija, loše ishrane ili skrivenih hemoroida, a kod žena zbog prestanka menstrual-nog ciklusa. Način lečenja ove bolesti se, prema ovom autoru, poklapa sa onim za koji su se zalagali raniji vizantijski autori. Takođe je preporučivao uopšteno lečenje melanholije, i posebne simptomatske tretmane u slučaju hemoroida (operacija) i menstrualnih anomalija. Na kraju, autor je preporu-čivao diuretike i perspirante. Novija istraživanja [19,20] pružaju dokaze da je ovaj anonimni pisac verovatno bio Pavle iz Nikeje, čuveni vizantijski lekar iz VII veka n.e.

Mihajlo Psel, lekar i čuveni filozof kasnijeg doba (XI vek n.e.), u svoju pesmu “Carmen de re medica” uključio je i opis u to vreme poznatih bolesti [21]. Kratko je primetio da je likantropija ne samo oblik melanholije, već i mizantropije, pošto je pacijent izolovan od društva. Bolesnika je opisao kao bledog, potištenog, sparušenog i zapuštenog izgleda.


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Poslednji čuveni vizantijski lekar, Jovan Aktuarije (XIV vek n.e.), koji je objedinio znanja svih lekara dugog vizantijskog perioda, bavio se me-lanholijom u poglavlju “O melanholičnim bolestima” [18]. U opis je uklju-čio i slučajeve pojedinaca koji su verovali da poseduju božji dar predviđanja budućnosti, ili su se plašili bezopasnih svakodnevnih događaja, ili bezrazlož-no izbegavali društvo ljudi ili razgovor sa njima, ćutljivi, tužni i povučeni. Opisao je i druge, koji su se ili plašili smrti ili je priželjkivali, uz misli o sa-moubistvu. Klinička slika koju je pružio ista je kao kod ranijih lekara, po-sebno u slučajevima likantropije. Tvrdio je da bolesnici noću lutaju po grob-ljima i usamljenim mestima, poput vukova, a preko dana se vraćaju svojim domovima, gde je njihovo ponašanje naizgled normalno.

Diskusija Prvi opis likantropije dao je lekar Marsilije Siditski (tj. iz Sidije,

grada u Maloj Aziji), koji je bio sledbenik aleksandrijske pneumatske škole i živeo u Rimu (II vek n.e.). Većina Marsilijevih dela je izgubljena. Među onima koja su sačuvana, može se izdvojiti njegovo delo o likantropiji ili ki-nantropiji. U svojoj knjizi koja je sadržala razna medicinska mišljenja o me-lanholiji, Galen je citirao značajan izvod iz dela svog savremenika Marsilija [22]. Sam Marsilije je likantropiju smatrao jednim oblikom melanholije.

Ova bolest je kasnije smatrana zooantropskim delirijumom, pošto je pacijent bio uveren da se pretvorio u vuka [3]. Ovu vrstu transformacije već je opisao Hipokrat [3]. Bila je poznata i u vizantijsko doba, i veliki vizantij-ski lekar, Aleksandar Tralski (VI vek n.e.), iako nije opisao likantropiju per se, predstavio je nekoliko slučajeva melanholije komplikovane raznim vrs-tama čudnih fantazija [23]. Konkretno, opisao je pacijente koji veruju da su crepovi, ili životinjske kože, ili petlovi, i imitiraju njihovo kukurikanje. Neki drugi pacijenti su imali fantazije inspirisane grčkom mitologijom; verovali su da su slavuji koji plaču jer su izgubili Itija (mitološka ličnost) ili da su Atlas koji podupire nebeski svod, i plašili se da bi on mogao da padne i uništi i njih same i ceo svet.

Oribasije, koji je sastavio prvi medicinski opis likantropije u vizantij-sko doba, bio je paganin i prihvatio je Marsilijev pristup. Klinički opis i na-čin lečenja koji su predložili bili su prilično slični, mada su se razlikovali u nekim tačkama. Međutim, uticaj starih naroda još uvek je bio očigledan dva veka kasnije, kada je hrišćanin Ecije gotovo od reči do reči usvojio Marsili-jeve koncepte i etiološki pristup. Marsilije je isticao da je likantropija men-talna bolest, a ne stvarni fenomen, pošto je nemoguće da se ljudsko biće fi-zički preobrazi u vuka. Bolesnik veruje da se u njemu odigrala magična pro-mena [3]. Prema tome, Marsilije je očigledno pokušao da obuzda magijska verovanja svog vremena u korist medicinske realnosti, zastupajući stav da je likantropija psihoza, a ne magijski preobražaj.

Koncept likantropije su kasnije usvojili islamski doktori; prema Dol-su [14], iz Ecijevih tekstova. Moguće je, međutim, da su arapski lekari bili


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upoznati sa ovom temom preko radova Galena, Oribasija, Pavla iz Nikeje, ili čak Pavla Eginjanina, koji su opisali slične kliničke slike i čija su dela bila poznata u islamskoj literaturi. Rad kasnijih vizantijskih lekara imao je snažan uticaj na medicinske koncepte kod Arapa [24]. Razes je doslovce prihvatio mišljenja Vizantinaca; drugi su, kao Abulkasis, dodavali neke elemente tera-pije kao što je kauterizacija glave, metod koji se nije nalazio u vizantijskim ili Galenovim tekstovima. Drugi arapski lekari smatrali su da je ova bolest nasledna i teško izlečiva [14].

Prema Dolsu [14], likantropija predstavlja dobar primer sindroma iz ovog perioda koji su isključivo teorijski. Ne postoji nijedan sličan opis u srednjovekovnoj islamskoj literaturi. Prema tome, moguće je da je klinička slika likantropije izvedena iz grčke medicine [13]. Kasnije je ovu kliničku sliku prihvatila i zapadnoevropska medicina, i to ili direktno iz vizantijskih medicinskih tekstova ili, što je češći slučaj, posredno, preko prevoda arap-skih tekstova na latinski [13].

Čini se da je ova bolest, koju karakterišu lutanje oko grobnica preko noći i vraćanje u svakodnevnu rutinu preko dana, slična mitu o vampirima, koji se može naći u mnogim kulturama širom sveta [25].

Da zaključimo: mnogi vizantijski lekari detaljno su opisali kliničku sliku likantropije. Neki osnovni simptomi ovog poremećaja, kao što je druš-tvena izolacija, mizantropija, potištenost i nemar prema spoljašnjem izgledu, ubrzo su ih naveli da ovo stanje klasifikuju kao mentalni poremećaj, u skla-du sa shvatanjem Marsilija, koji ga je prvi opisao. Preciznije, vizantijski le-kari klasifikovali su likantropiju kao oblik depresije (melanholični tip, ili psihotična depresija). Treba napomenuti da ni Marsilije, iako je bio paganin, ni hrišćanski vizantijski doktori, nisu verovali da je ovaj poremećaj magij-skog ili demonskog porekla, već su smatrali da je reč o duševnoj bolesti. Njihovi stavovi su neposredno ili posredno uticali na arapsku i zapadnoev-ropsku medicinu.

Psihijat. dan. /2005/37/2/329-334/ Kontaxakis P. V. Lycanthropy according to Byzantine physicians

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General article

UDK: 616. 89 - 008 (495.02) 616. 89 (091)

LYCANTHROPY ACCORDING TO BYZANTINE PHYSICIANS

Vassilis P. Kontaxakis1, †John G. Lascaratos2, Panayotis P. Ferentinos1,

Maria-Irini V. Kontaxaki1, George N. Christodoulou1

1Department of Psychiatry, University of Athens, Greece 2History of Medicine, University of Athens, Greece

Abstract: The purpose of this paper is to review texts about lycanthropy in Byzantine medical literature and to appreciate their impact on medicine thenceforth. The original Greek language texts of the Byzantine physicians, such as Oribasius (4th century A.D.), Aetius (6th century A.D.), Paul of Aegina (7th century A.D.), Paul of Nicea (7th century A.D.), Michael Psellus (11th century A.D.) and Joannes Actuarius (14th century A.D.), were examined. The existing texts of ancient Greek and Roman physicians were also reviewed. Byzantine physi-cians provided detailed descriptions of the clinical picture of lycanthropy as well as sugges-tions about its treatment. They believed lycanthropy to be a form of melancholic or psychotic depression and not demonic in origin, being in line with the Roman physician Marcellus Sid-ites (2nd century A.D.), who first described the syndrome. The views of Byzantine physicians about lycanthropy have directly or indirectly influenced the way Arabic and Western European medicine have later dealt with it.

Key words: Byzantine medicine, history of medicine, lycanthropy, depression, melan-

choly, psychosis


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Introduction Lycanthropy is the delusional belief of having been transformed into

an animal, traditionally a wolf [1,2]. The term lycanthropy originated from the Greek words lycos = wolf and anthropos = man. The first descriptions of the syndrome can be found in Greek mythology. Demigod Lycaon was trans-formed by Zeus into a wolf as a punishment for his attempt to feed Zeus with the flesh of a young boy he had sacrified [3]. A later description of the syn-drome is found in the Bible. In the Book of Daniel a divine punishment was inflicted upon the Babylonian King Nebuchadnezzar; he was transformed into an ox for seven years [4,5].

In the beginning of the 19th century lycanthropy was considered as a mental disorder [6]. During the 20th century, several case reports of lycan-thropy were published in the international literature. Most of them concerned patients suffering from affective or psychotic disorders. Further cases of man-animal metamorphoses were reported in patients with other mental dis-orders, including personality disorders, hysteria, alcohol or drug abuse, or-ganic brain syndromes, dementia, and epilepsy [7-11].

The purpose of this study is to show that the works of Byzantine physi-cians on lycanthropy provided new data and offered clearer interpretations of this condition; moreover, they provide evidence that since ancient times lycanthropy had been thought to be a mental disease.

Byzantine medicine is, in fact, the continuation of ancient Greek, Hellenistic and Roman medical tradition, as well as the vital link to Western European medicine, which it influenced directly or indirectly, via the works of Arab physicians. The investigation of the writings of Byzantine physicians is of significant interest because most of them reproduce the essence of the writ-ings of ancient Greek physicians, many of which are now lost, without failing to supply their own contribution at the same time [12]. The great Byzantine doctors, from Possidonius and Oribasius (4th century A.D.) to Joannes Actu-arius (14th century A.D.), provided many clinical descriptions of psychiatric in-terest, which they compiled from the works of ancient physicians, especially Hippocrates (5th century B.C.), Galen (2nd century A.D.), Aretaeus (1sl- 2nd cen-tury A.D.), Soranus from Ephesus (1s t - 2nd century A.D.) and others. Apart from lycanthropy, a series of other mental disorders were described in their works, such as mania, melancholy, cataphora (profound depression), phrenitis, love-sickness, incubus (nightmare), lethargy, insomnia, senile cerebral atro-phy (a type of dementia), alcoholic intoxication and epilepsy [13].

Material The first Byzantine physician to deal with lycanthropy was not Aetius,

as referred to by some authors [14], but Oribasius (4th century A.D.), who wrote the first chapter of Byzantine medical literature on this topic, entitled “On Lycanthropy” [15]. Oribasius wrote that lycanthropes circulate at night, usually stay around tombs until dawn, and behave exactly like wolves. The


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recognition of these sufferers was achieved by noting the following signs and symptoms. They are pale and gaze vacantly with dry eyes deep in their sockets, without producing tears. Their tongue is dry and they do not produce saliva at all. They are always thirsty and their shins are usually injured be-cause they often stumble against objects. According to Oribasius the dis-ease was diagnosed as a form of melancholy. The treatment during the chronic phase included calming the patient, extended venesection until the sufferer fainted, baths in fresh (non-salt) water, while fluid-intake was encour-aged. Later on, a fat-free milk diet and holy marrow herb purgatives were administered for three days. This was repeated three times (a total of nine days). Then, theriac-containing snakes, the usual remedy for melancholy in that time, were administered. In the acute phase of the disease, somniferous inunctions into the ears and nostrils, most often containing opium, were used.

The second eminent Byzantine physician dealing with lycanthropy was Aetius (6th century A.D.), who wrote a chapter entitled “On Lycan-thropy, that is cynanthropy, according to Marcellus” [16]. Aetius described the behavior of sufferers in the same way as Oribasius and added that lycan-thropes wander at night in February, imitating wolves or dogs. He provided the same clinical picture as Oribasius, adding that the wounds of the shins are due to repeated falls and dog bites and are incurable. He also considered the disease as a form of melancholy and suggested a similar treatment as Oribasius. He went on to add some new purgatives, such as the “holy drugs” of Rufus, Archigenes and Justus. Before an imminent evening crisis, he also recommended soporifics and similar substances, in particular opium, administered either as inunctions into the nostrils or in some rare cases per os.

Paul of Aegina (7th century A.D.) was in line with the two previous authors. He entitled his relevant chapter “On Lycanthropy or Lycaon”, implying connotations inspired from Greek mythology [17].

Another anonymous writer [18] of a chapter on lycanthropy agreed with the ideas of Oribasius and Aetius and added that lycanthropes are un-usually slim, which is a characteristic of melancholy. Their melancholic con-stitution is either congenital or acquired, resulting from insomnia, life stressors, bad diet or blind hemorrhoids and, in women, a cessation of the menstrual cy-cle. According to the author, the treatment of the disease coincided with that advocated by earlier Byzantine writers. He further recommended general treatments of melancholia and special causative treatments in cases of hemor-rhoids (surgery) and menstrual anomalies. Finally, the author suggested diu-retics and perspirants. Recent researches [19,20] have provided evidence that the anonymous writer was probably Paul of Nicea, an eminent Byzantine physician of the 7th century A.D.

A later physician and eminent philosopher, Michael Psellus (11th

century A.D.), included in his poem “Carmen de re medica” a description of the known diseases in that time [21]. He noted briefly that lycanthropy is not only a form of melancholy but also misanthropy, since the patient is isolated


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from society. He described the sufferer as pale, dejected, dry, and care-less of his appearance.

The last famous Byzantine physician, Joannes Actuarius (14th century A.D.), who summarized the knowledge of all the physicians of the extensive Byzantine period, dealt with melancholy in his chapter “On Melancholic Dis-eases” [18]. He included cases of individuals believing that they had the di-vine gift of forecasting the future, or fearing harmless everyday events, or un-reasonably avoiding the company of or conversation with people, remaining silent, sad and withdrawn from society. Finally, he described others who either feared death or desired it, having suicidal thoughts. In lycanthropy cases, in particular, he provided the same clinical picture as earlier physicians. He argued that at night sufferers wander around cemeteries and lonely places like wolves; while during daytime they return to their homes, where their behavior is apparently normal.

Discussion The first description of lycanthropy was given by the physician Mar-

cellus Sidites (i.e. from Sydia, a town in Asia Minor), who was a follower of the Pneumatic School of Alexandria and lived in Rome (2nd century A.D.). Most of Marcellus’ works have been lost. Among the remaining ones, his work on lycanthropy or cynanthropy can be singled out. Galen quotes a relevant extract of his contemporary Marcellus’ work in his book containing various medical opinions on melancholy [22]. Marcellus himself consid-ered lycanthropy to be a form of melancholy.

The disease was later considered to be zooanthropic delirium, as the patient thought he had been transformed into a wolf [3]. This kind of trans-formation had already been described by Hippocrates [3]. It was also known in Byzantine times, as a great Byzantine physician, Alexander of Tralles (6th century A.D.), presented several cases of melancholy complicated with dif-ferent kinds of strange fantasies, although he did not describe lycanthropy per se [23]. In specific, he described patients who believed they were roof-tiles, or animal skins, or cockerels, imitating their crowing. Some other pa-tients had fantasies inspired from Greek mythology; they believed they were nightingales crying because they had lost Itis (a mythological figure) or they believed they were Atlas supporting the globe, fearing that it might fall and de-stroy themselves and the whole world.

Oribasius, who compiled the first medical description of lycanthropy in Byzantine times, was a pagan and he adopted Marcellus’ approach. The clinical description and treatments they proposed were quite similar, although different in some points. However, the influence of the ancients was still evi-dent two centuries later, when the Christian Aetius adopted, almost verba-tim, Marcellus' concepts and etiological approach. Marcellus pointed out that lycanthropy was a mental disease and not a real phenomenon, as it is impossi-ble for a human being to be transformed physically into a wolf. The sufferer


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believes that a magical change has taken place within him [3]. Thus, Marcellus obviously harnessed the magical beliefs of his time to the medical reality, ad-vocating that lycanthropy is a psychosis and not a magical transformation.

The concept of lycanthropy was later adopted by Islamic doc-tors; according to Dols [14], from the work of Aetius. It is, however, possi-ble that Arab physicians could have known this from the works of Galen, Oribasius, Paul of Nicea or even Paul of Aegina, who described similar clinical pictures and whose works were known in the Islamic literature. The work of the later Byzantine physicians deeply influenced the medical concepts of the Arabs [24]. Razes adopted verbatim the opinions of the Byzantines; others like Abulcasis added some therapeutic elements such as cauterization of the head, a method not included in Byzantine or Galenic texts. Other Arab physicians considered the illness inherited and hardly curable [14].

According to Dols [14], lycanthropy represents a good example of the purely notional syndromes of this period. No similar description in the medieval Islamic literature exists. Thus, it is possible that the clinical picture of lycan-thropy was derived from Greek medicine [13]. Later, this clinical picture was adopted by Western European medicine either directly from the Byzantine medical texts or, mainly, indirectly from translations of the Arabic works into Latin [13].

It seems that the disease, characterized by wandering around tombs at night and returning to everyday routine during daytime, resembles the myth of vampires, which can be found in many cultures worldwide [25].

In conclusion, many Byzantine physicians have described the clini-cal picture of lycanthropy in detail. Some main symptoms of the disorder, such as social isolation, misanthropy, dejection and carelessness of one's ap-pearance, have led them to early classify this condition as a mental disorder, in line with the concepts of Marcellus, who first described it. In specific, Byzan-tine physicians have classified lycanthropy as a form of depression (melan-cholic type or psychotic depression). It is worth noting that neither Marcel-lus, though a pagan, nor Christian Byzantine doctors thought that the disor-der was magical or demonic in origin, and they believed it to be a mental ill-ness. Their views have directly or indirectly influenced Arabic and Western European medicine.

References

1. Coll PG, O' Sullivan G, Browne PJ. lycanthropy lives on. Br J Psychiat 1985 147: 201-202.

2. Verdoux H, Bourgeois M. A partial form of Lycanthropy with hair delusion in a manic-depressive patient. Br J Psychiat 1993 163: 684-686.

3. Roccatagliata G. A history of Ancient Psychiatry. New York: Green-wood Press; 1986.

4. Arieti S. American handbook of psychiatry. Vol. 3. New York: Basic Books; 1974.


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5. Rosner F. Julius Preuss' Biblical and Talmudic medicine. New York: Hebrew Publishing Company; 1983.

6. Esquirol J. Des maladies mentales. Vol. 1. Paris: Bailliere; 1838. 7. Keck PE, Pope HG, Hudson JI, McElroy SL, Kulick AR. Lycanthropy:

Alive and well in the twentieth century. Psychol Med 1988 18:113-120. 8. Fahy TA. Lycanthropy: A review. J Roy Soc Med 1989 82:37-39. 9. Rao K, Gangadhar BN, Jayakiramiah N. Lycanthropy in depression: Two

case reports. Psychopathology 1999 32:169-172. 10. Verdoux H, De Witt J, Benezeh M. La lycanthropie: Une pathologie

contemporaine? Annales de Psychiatrie 1989 4:176-179. 11. Garlipp P, Godecke-Koch T, Dietrich DE, Haltenhaf H. Lycanthropy –

psychopathological and psychodynamical aspects. Acta Psychiatr Scand 2004 109:19-22.

12. Lascaratos J, Cohen M, Voros D. Plastic surgery of the face in Byzantium in the fourth century. Plast Reconstr Surg 1998 102:1274-1280.

13. Mettler CC. History of medicine. Philadelphia: The Blakiston Co.; 1947. 14. Dols MW. Majnun. The Madman in Medieval Islamic Society. Oxford:

Clarendon Press; 1992. 15. Raeder I. Oribasii Synopsis ad Eustathium. Libri ad Eunapium. Amster-

dam: Hakkert; 1964. 16. Olivieri A. Aetii Amideni Libri Medicinales V-VIII. Berolini: Academia

Litterarum; 1950. 17. Heiberg IL. Paulus Aegineta. Vol. 1. Lipsiae et Berolini: Teubner; 1921. 18. Ideler IL. Physici et Medici Graeci Minores. Vol. 2. Amsterdam: Hak-

kert; 1963. 19. Zervos S. Identification of the authors of two anonymous medical texts.

Athens, 20:1908 502-508. 20. Ieraci Bio AM. Paolo di Nicea. Manuale Medico. Napoli: Bibliopolis;

1996. 21. Ideler IL. Physici et Medici Graeci Minores. Vol. 1. Amsterdam: Hak-

kert; 1963. 22. Kuhn CG. Claudii Galeni Opera Omnia. De Melancholia ex Galeno, Rufo,

Posidonio et Marcello, Sicamii Aetii Libellus. Vol. 19. Lipsiae: Cnobloch; 1830.

23. Puschmann T. Alexander von Tralles. I. Band. Amsterdam: Hakkert; 1963.

24. Ullmann M. Islamic medicine. Edinburgh: Edinburgh University Press; 1978.

25. Gonez-Alonso J. Rabies. A possible explanation for the vampire legend. Neurology 1998 51:856-859.

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Doc. dr Vasilis P. KONTAKSAKIS, Univerzitet u Atini, Psihijatrijsko ode-ljenje bolnice “Eginition”, Grčka

Vassilis P. KONTAXAKIS, MD, PhD, Associate Professor of Psychiatry, University of Athens, Greece


Psihijat. dan. /2005/37/2/335-340/ Petrović N. Dvojstvo žene

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Stručni rad

UDK: 159. 923 - 055.2

DVOJSTVO ŽENE

Nataša Petrović Stefanović1 i Stevan P. Petrović

1Institut za mentalno zdravlje, Beograd, Srbija i Crna Gora

Apstrakt: Lilit kao psihološka datost prisutna je u podsvesti i svesnim sferama ljudi

više hiljada godina i, uprkos raznim transformacijama i metamorfozama, ostala je podjednako aktuelna do danas, reinkarnirajući pod svim podnebljima arhetipsku matricu nikada ponovlji-ve, zastrašujuće i dijabolične ženskosti. U mitologiji je poznata kao demonica, žderačica muš-karaca i ubica dece.U psihološkom smislu Lilit može biti mračni aspekt ženske seksualnosti, arhetipska ženskost u ogoljenoj formi, koja nosi u sebi ogromne količine zloćudne agresivnos-ti i osvetničko ponašanje, nasuprot pokornoj i prijemčivoj Evi. Njene moći najizraženije su na najvažnijim raskrsnicama u životu žene: u pubertetu, pred menstruaciju, na početku i kraju trudnoće, materinstva i menopauze. Kako je Lilit u velikoj meri prisutna u svakodnevnom ži-votu kao i u psihopatologiji, pitamo se zaslužuje li da u stručnoj literaturi dobije poseban enti-tet, kakav su, recimo, dobili Edip, Don Žuan, Otelo.

Ključne reči: Lilit, ličnost žene, prvobitna Eva


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Uvod Mračna i tajanstvena Lilit, kao psihološki ideogram za mračnu stranu

žene, bez obzira na njena druga imena pod kojima se prikazuje i kao jedin-stveno mitsko biće, prisutna je u nesvesnom čoveka, širom planete, više hi-ljada godina [1]. Iako se u svojim manifestacijama iskazuje kao strašna i is-tovremeno neodoljivo privlačna figura nejasnih košmara, koji užasavaju muš-karce i bude ih preplašene iz njihovih snovnih lutanja s onu stranu jave, sa pratećom grižom savesti zbog opsesivne pretpostavke da je noćna mora sa Lilit u glavnoj ulozi kazna ili opomena za privlačne fantazme o preljubi, Lilit je neprekidno iskušenje za sve muškarce koji pokušavaju da je izbegnu po svaku cenu, ali u tome nikako ne uspevaju, jer ona predstavlja otelovljenje svih njihovih potajnih poligamnih želja, kojih ne mogu da se odreknu, zbog njihovog teško kontrolisanog nagona za stalnim doživljavanjem novog i dru-gačijeg, onoga što nikada nisu doživeli sa svojim ženama. Kada iracionalno preovlada u muškarcu, umesto razumne odbrane od smrtonosnih izazova Li-lit, uz pakleno privlačnu lepotu i pohotu koja zrači iz ove tajanstvene žene, tada nema ni govora o bilo kakvom vidu razumne odbrane od smrtonosnih izazova Lilit, koja upravo ide u susret svim njegovim potajnim željama. Ka-da konačno osvoji muškarca, maska neodoljivo privlačne žene joj spada sa lica i ona se prikazuje u svojoj originalnoj slici, kao nakazna spodoba, ptičjih nogu sa dugim kandžama, čiji spoljni izgled ledi krv u žilama muškaraca, koji su se u prvom trenutku predali neodoljivim izazovima njenih lažnih čari, koje su prisutne sve dok ne osvoji i ne podjarmi muškarca. Ali tada je, naj-češče, sve kasno. Povratka u prvobitno stanje nema. Kazni užasne Lilit ne može se više umaći. U tom smislu, ona je prikazana kao Monada, jer je je-dinstvena razorna sila, kao inkarnacija radikalnog i apsolutnog zla, koje is-punjava njeno kompletno biće. Dobrota je njenom biću nepoznata moralna kategorija, čak i u najskrivenijim naznakama. A to radikalno zlo, imanentno pripisano ženama, potiče od strane muškaraca koji su pisali mitologiju, i nije nimalo bez značaja, jer se kroz ovakve ženske likove često, tokom istorije, ispoljavalo kroz mizoginiju, strah pomešan sa mržnjom prema svojoj tajans-tvenoj družbenici. Čak i najbrutalniji muškarci zaziru od nečega nepoznatog u svojim ženama, koje ne mogu da dokuče do kraja, ali koje doživljavaju kao nešto latentno opasno. To je nešto što muškarca tera na stalnu opreznost u odnosima sa ženom. I, kako bi uspostavili kakvu-takvu ravnotežu sa svojim ženskim partnerom, reaguju nasiljem.

Mitska Lilit Jedinstvena priča o Lilit, onakva kakvu je danas znamo, nikada nije

postojala u svetskoj mitologiji. Pojedinačni zapisi o demonici noći ili mrač-noj strani žene koja se konačno, nakon mnogo vekova, otelotvorila kao je-dinstveni ženski entitet pod nazivom Lilit, začeli su se u različitim delovima sveta, u različitim vremenskim epohama. I, uprkos brojnim transformacijama i metamorfozama, ovo biće reinkarnira na svim podnebljima arhetipsku mat-


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ricu zastrašujućeg i dijaboličnog aspekta ženskosti, koje je u mitologiji raz-nih naroda poznato kao demonica, žderačica muškaraca i ubica dece [2].

U apokrifnim spisima se može naći pod raznim imenima, skrivena iza različitih likova: kao kraljica Zamaragda, kraljica od Sabe, zmija Serpent iz Edenskog vrta, koja navodi Evu i, posredno, Adama na greh, Kali, Hekata, Morgan le Fej, Lorelaj, pa i Šekspirova ledi Makbet, u dramskoj literaturi, i još mnoge druge zastrašujuće figure.

Dve figure koje su prethodile Lilit a koje su sa njom povezane na najočigledniji način, i koje bismo posebno istakli, vavilonska su demonica Lamaštu i njena grčka verzija Lamija [3,4]. One se, takođe, vezuju za proždi-ranje muškaraca i čedomorstvo. Ova dva primera, kao i mnogi drugi, uz Lilit, živi su dokaz da postoji inkorporirana, ko zna kada, tokom evolucije ljud-skog roda, neka kobna greška, duboko skrivena, koja se pokatkad budi u vidu radikalnog zla, usmerenog protiv svoga prirodnog para i njegove dece. Ova stvarna greška samo je personifikovana i zaogrnuta datost u plašt mita, kako bi se njeno postojanje približilo običnom čoveku.

Tumačenja Lilit su brojna i kontroverzna, ali su, svakako, najpoznati-ja ona o prvoj Evi, čiji se koreni mogu naći još u drugom veku, u Midrašu, koji predstavlja formu aktivnog promišljanja ili meditacije na temu biblijskih predanja, naročito onih iz Prve i Druge knjige Postanja, gde srećemo dve kontradiktorne verzije o stvaranju čoveka [5]. Prema jednoj, čovek i žena su stvoreni istovremeno, takoreći ni iz čega, ili iz praha zemnog, po obličju Tvorca, a prema drugoj, stvaranju Eve prethodilo je stvaranje usamljenog Adama. Kao što znamo, pravoverni Jevreji i hrišćani prihvatili su tu drugu verziju kao zvaničan stav vere [6].

Prvo pisano objašnjenje o postojanju Lilit, kao prvoj Adamovoj ženi, dato je u jednom komentaru, poznatom kao Alfabet ben sira, za koji se veruje da je nastao izmedju VII i X veka nove ere [7]. Ova ideja je kasnije dalje raz-vijana, tako da u XIII veku dostiže vrhunac u Kabali, posebno u klasičnom tekstu jevrejskog misticizma, poznatom pod imenom Zohar [8]. Dakle, za razliku od starozavetnih biblijskih spisa, koji poznaju samo Evu, kao prvu Adamovu ženu, u rabinskoj literaturi prvi put se spominje jedna druga žena, kao prva Adamova družica, pre nego što je Bog stvorio Evu i koja u jevrej-skom folkloru nosi ime Lilit. Ona je smatrala da bi, kako su istovremeno stvoreni, iz praha zemlje, dakle, iz iste materije i od strane istog Tvorca, muš-karac i ona u svemu trebalo da budu ravnopravni. Ali, Adam ne prihvata to obrazloženje, jer se povinuje savetima Tvorca, i nadalje zahteva pokornost i bespogovornu poslušnost, tvrdeći da je on kao slika Elohima, njen gospodar i vlasnik. Njeno suprotstavljanje jednoj nepravdi u osnovi je pravično, ali je izvedeno na pogrešan način, u kojem je unapred sebe osudila da bude gubit-nica, suprotstavljajući se protivniku koji je bio prejak za Nju. Međutim, gnev koji je obuzima u tom trenutku pomućuje joj razum i ona pribegava iracio-nalnom ponašanju. U jednom trenutku obraća se rečima Neizrecivom, raz-mahuje krilima i nestaje u nebeskom prostranstvu, putujući put demona, ka


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Crvenom moru, gde se nastanjuje i udaje za Samaela, slepog kralja demona, i sâma postaje kraljica i majka demona.

Bog šalje tri anđela da je vrate, što ona odbija i biva kažnjena straš-nom kaznom da gubi stotinu dece svaki dan. Nad telima mrtve dece i sa oči-ma bez suza, zaklinje se na večnu osvetu Adamu, da će mu od sada ubijati svu decu i decu njegove dece, sve dok je roda ljudskog, jer ona je besmrtna. Nakon toga, Bog uslišava molbu Adamovu, i stvara Evu iz rebra Adamovog, kao simbolički akt podvrgavanja žene muškarcu, čime se izbegava ponavlja-nje prvobitnog konflikta i dileme oko prvenstva i dominacije. Adam je, da-kle, prvostepeno ljudsko biće, a tek zatim Eva iz dela tela njegovog, kao za-loga pripadanja i poslušnosti svome čoveku [9].

Napuštajući Edenski vrt i Adama, Lilit zapravo započinje dugi put večnog revanša, nikada u potpunosti zadovoljenog, pa zbog toga i repetitiv-nog, zbog poniženja koja je doživela kao prva žena od svog Božjeg izabrani-ka. Ona prema svim opisima, bez obzira na poreklo ili versku pripadnost, ote-lovljuje suštinsku vezu između ženskog i demonskog, drugim rečima, ubitačnu dimenziju nedeljivu od ženskosti, sa osnovnom nakanom da ospori navodnu savršenost i neprikosnovenost muškog aspekta među bićima ljudskog roda.

Psihologija žene Ako govorimo o psihologiji žene, neki aspekti mogu se nazreti već u

Zoharu, u kome se Lilit smatra Bludnicom, Prokletnicom, Grešnicom ili Cr-nom, i upozorava muškarce da uvek budu na oprezu, jer svaka žena, pa čak i Evina kći, nosi u sebi skrivene moći Lilit, u svom delu Anime [8]. Dakle, s jedne strane imamo Evu, koja predstavlja roditeljsko-instinktivni aspekt žen-skog načela, koja štiti, hrani i oličava život i, sa druge strane, Lilit koja je nje-na suprotnost, osvetoljubiva, zla i koja može doneti i smrt. Ona je mračni as-pekt ženske seksualnosti, okeanska i arhetipska ženskost u ogoljenoj formi, naglašavamo, ona je više ideja o jednom aspektu ženske prirode, nego sâma priroda žene. Ona je, u svetlosti Jungove analitičke psihologije, deo onog mrač-nog dela Anime, koji je u stalnom sukobu sa božanskim i nepromenljivim poret-kom stvari, koji ženu svodi na korisnu animalnost i sredstvo muške naslade [10].

Ovo dvojstvo ženske prirode najočiglednije je tokom menstrulanog ciklusa. U prvoj polovini, jača je Eva. Očekujući ovulaciju i, možda, začeće, žena se oseća otvoreno, prijemčivo i povezano sa svetom i životom. Ukoliko do začeća ne dođe, Eva se povlači a Lilit preuzima primat. Nada ustupa mesto očaju. Uopšte, moći Lilit su najizraženije na najvažnijim raskrsnicama ženskog života: u pubertetu, na početku i kraju trudnoće, materinstva i menopauze.

U pogledu patologije Lilit bi mogla biti odgovorna za rane i kasne gestoze, spontane pobačaje, PMS, postpartalne psihoze i depresije, čedomor-stvo i sl. Isto tako, ona je personifikacija za neobjašnjive događaje i fenome-ne koji se dešavaju u realnom svetu kao što su noćne polucije ili SIDS (Sudden Infant Death Syndrome – sindrom iznenadne smrti odojčeta), koji se odnosi na smrt inače potpuno zdravih beba tokom sna i još uvek je nepoznate etiologije.


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Bezbroj je pitanja koja se baziraju na zdravorazumskim promišlja-njima, a Lilit im svima izmiče i definitivno ostaje neuhvatljivi aspekt mračne strane žene, koji nema svoj pandan u okviru muškog pandemonijuma. Možda joj je po količini zla koje nosi u sebi jedino približan Asmodej, sin Name i Šamdona, demon i duh koji u muškarcima budi toliku požudu da ovi ne mo-gu odoleti da ne iznevere svoje supružnice, uvek spreman da ubije svakog muškarca koji bi mu bio prepreka u osvajanju žena [3]. Taj demon persijskog porekla, koji se pojavljuje i u hebrejskom predanju, bio je otelotvorenje zle energije i sejač užasa. Ili, u lepoj književnosti, možda, mračni Hitklif.

Nije isključeno da je dvosmislena i višeznačna ličnost Lilit, kraljice i majke demona, tačno određena, osvetljena, uzdignuta od celog svog mitskog dvora, u psihoanalitičkom smislu ishod vanrednog simboličkog zgušnjava-nja. Ona je imaginarni i sintetički spreg raznih, pa i protivrečnih, pretpostav-ki ili predstava, koje upućuju na različita arhetipska bića, čije matrice nosimo u sebi a da toga nismo ni svesni.

Konačno, možda jedno diskretno obeležje ove mitske žene nije ma-nje značajno, kada se razmatraju motivi njenih ponašanja. Lilit je u dubini svoje duše žena koja je doživela razočaranje i poraz u ljubavi, ili u svojoj želji za ostvarivanjem materinstva sa voljenim čovekom; jer, ona je u počet-ku Adama odista volela nesebičnom i snažnom ljubavlju, a ni za jednog dru-gog muškarca nije mogla znati, izuzev za Adama, koji ju je nekada, na neki način, neoprostivo uvredio i ponizio. A to razočaranje, bez oprosta, možda, objašnjava mnoge stvari. Od svojih prapočetaka, ona se nikada ne eksponira kao borac koji treba da povrati svoje izgubljene pozicije kod voljenog čove-ka, već isključivo kao surovi osvetnik. Neugasiva žudnja za osvetom je njeno jedino duhovno obeležje. Nije li to znak njene primalne slabosti i straha od poraza ukoliko uđe u otvorenu konfrontaciju sa muškarcem ili neuspešni po-kušaj da se pomiri s njim? Strah da ne izgubi bitku sa Evom, koja ju je nje-nom krivicom potisnula, pomračuje njen noetski horizont i pretvara je u ira-cionalno zlo, koje ne poznaje nikakve granice i skrupule.

Obračun sa decom uvek je u osnovi pomeren obračun sa njihovim ocem, nastavljačem loze Adamove. Ubijanje dece, koja su prirodni nastavlja-či života, i uništavanje muškog semena kroz noćne polucije, zapravo je borba protiv nastavka života, u jednom širem smislu. Na ovaj način njeno zlo je još ubitačnije i ide još dalje, a ona biva još strašnija i zlokobnija u svojim pakle-nim namerama, jer se ne bori samo protiv Ljudi, već i protiv samog Tvorca života, i života, samog po sebi, na jedan posredan način.

I pored mnogih intelektualnih spekulacija o prirodi Lilit, koje mogu manje više da imaju neku svoju logiku, ipak ne možemo do kraja da budemo zadovoljni našim poznavanjem porekla motiva za ovakva ponašanja zagonet-ne Lilit. Prinuđeni smo da se uvek iznova vraćamo na isto pitanje: zašto se Lilit tako lako odrekla svoje ženskosti, u svim aspektima, a zadržala samo svoj demonski aspekt, neobično slična Šekspirovoj ledi Makbet? Bespogo-vorno i zauvek. Zašto se povukla pred Evom i prepustila joj da bude Velika


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majka i žena Adamova, iako je tu ulogu Tvorac primarno dodelio njoj? Da bude Pramajka ljudskog roda? Nigde se ne vidi njen primarni rivalski odnos prema novostvorenoj Evi, od istog Tvorca, koji je najpre stvorio nju. Zašto se odrekla svoga materinstva? Iz ponosa ili uvređenosti, zadržavši samo svoj nagonski seksualni i osvetnički aspekt, jer su seksualnost i strasna agresija dve veoma bliske psihološke kategorije, koje lako prelaze jedna u drugu, i jedna sa drugom razmenjuju energije?

Značaj za psihopatologiju Lilit živi i dela, i prisutna je u modernom vremenu, jer je ona jedino

božanstvo kome je suđeno da živi sve do Dana Sudnjeg. I danas je ona mrač-ni i razorni aspekt žene, podjednako opasan i za muškarce, žene i decu. Isti-na, danas Jevreji sve češće pokušavaju da je rehabilituju i njeno zlo sublimišu u feministički aspekt, i prikažu je kao borca za ženska prava, čije je ponašanje reaktivnog porekla, zbog teške uvrede koju joj je priredio Muškarac. Nismo sigurni koliko će u tome uspeti. U ovom pokušaju vidimo samo nevešti poku-šaj njene rehabilitacije, jer ona i danas deluje kao zao duh, i to kao čest gost u psihopatologiji i psihijatrijskim ordinacijama, što je čini aktuelnim zlom.

Lilit-majka nije nepoznata psihoterapeutima i njihovim pacijentima, čije su žrtve oličene u njihovoj deci, muževima, ljubavnim partnerima ili ženskim rivalima. Na ovom terenu Lilit se može pojaviti kao zavodnica svoje muške dece, uzročnica njihove zaljubljenosti u svoje majke, krivac za homo-seksualne nastranosti ili impotenciju svojih sinova. Lilit može zavesti muže-ve svojih kćeri i tako se svetiti mitskoj Evi. Ona tera muževe da noću prosi-paju svoje seme i na taj način uništava njihov porod.

Majka-Lilit, ili ona koja rađa decu demone, zaslužuje da u savreme-noj psihopatologiji dobije svoju posebnu nozografsku oznaku, jer je svepri-sutna i predstavlja permanentnu opasnost. A, pomalo je ima, vešto skrivene, i u Senci svake žene. Iako potiče iz mita, ona je u svakodnevnom životu i psi-hopatologiji toliko prisutna da bi među brojnim entitetima trebalo da dobije svoje mesto i ime, na primer, kao Lilit kompleks. Slično kao Edipov kom-pleks ili, recimo, Elektra kompleks, ili kompleks Don Žuana.

Nije isključeno da priča o Lilit pokušava da svedoči i simbolizuje iz-vesno osporavamje muškog poretka, koji sâm upravlja čak i “valjanim” funk-cionisanjem Vaseljene. Ne samo što ćemo u njoj videti Lilit, prvu ženu Adamovu, kako se buni protiv obaveze koju joj je nametnuo Upravljač svih stvari, da ostane ispod muškarca, nego ćemo videti i kako ona stiče povlasti-cu da se vine u “visine Univerzuma”, prisvajajući time prednosti uspona, koji su krilo i njegov vertikalni polet do tada metaforički čuvani samo za muškar-ca. Možda je njena razornost, samo na pometen način, shvaćena kao njena teško dokučiva hermetička poruka. Nije isključeno da će se u modernom vremenu, u nesigurnoj ravnoteži putenosti i duha, ponuditi zavodljiva i plod-na Lilit, kao vanvremena dimenzija između uvek pretećeg povlačenja nazad i ponekad izopačenog uzdizanja razuma.

Psihijat. dan. /2005/37/2/341-347/ Petrovic N. Duality of woman

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General article

UDK: 159. 923 - 055.2

DUALITY OF WOMAN

Natasa Petrovic Stefanovic1, Stevan P. Petrovic

1Institute of Mental Health, Belgrade

Abstract: Lilith as a psychological fact is present in the subconscious and

conscious spheres of mankind for several thousand years and, in spite of various transformations and metamorphoses, she remained as much present to this day, rein-carnating worldwide the archetypal matrix of the unique, terrifying and diabolic femininity. In mythology, she is known as the demoness, man-eater and murderer of children. In the psychological sense, Lilith can be the dark aspect of female sexual-ity, archetypal femininity in the naked form, carrying within herself immense quan-tity of malicious aggressiveness and vindictive behavior, as opposed to the submis-sive and receptive Eve. Her powers are at their highest during the crucial turning points in the life of a woman: in puberty, before menstruation, the beginning and end of pregnancy, in maternity and menopause. Having in mind the considerable pres-ence of Lilith in the everyday life, as well as in psychopathology, the question is raised whether she deserves to attain a special entity in the expert literature, as did, for example, Oedipus, Don Juan, Othello.

Key words: Lilith, personality of woman, primordial Eve


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Introduction The dark and mysterious Lilith, as a psychological ideogram for the

dark side of woman, regardless of other names she is presented by as a unique mythical being, exists in the unconscious man worldwide for several thousand years [1]. Although in her manifestations she is seen as a terrifying and at the same time irresistibly attractive figure from obscure nightmares, that horrify men and wake them from their dream-wanderings on the other side of reality, followed by guilty conscience due to obsessive presumption that the nightmare of Lilith is either a warning or a punishment for their at-tractive phantasms of adultery, Lilith is a never-ending temptation for all men who try to avoid her at any cost, but fail to do so, because she is the em-bodiment of all their secret polygamous desires they cannot renounce be-cause of their uncontrollable urge to constantly experience something new and different, that they have never experienced with their wives. When the man is overpowered by the irrational, instead of the rational defense from the fatal temptation of Lilith and the infernally attractive beauty and lust radiat-ing from this mysterious woman, there can be no rational defense from the fatal temptation of Lilith who is actually aiming to meet all his clandestine desires. When she finally conquers the man, the mask of the irresistibly at-tractive woman slips off her face and she is seen in her original image, as a monstrous creature, with bird’s legs and long claws, the mere sight of her freezing the blood in the veins of men who had surrendered to the irresistible temptation of her false charms, charms that are there only until she conquers and enslaves the man. But then it is too late. There is no turning back. The punishment of horrible Lilith cannot be escaped. In that sense, she is depicted as a Monade, for being a unique destructive force, as the incarnation of radi-cal and absolute evil, filling her entire being. Goodness is a moral category unknown to her, even in its most hidden indications. And the radical evil, immanently ascribed to women, comes from the men, the writers of mythol-ogy, which is not insignificant since often in the course of history, through female characters such as this, misogyny was expressed, the fear mixed with hatred toward their mysterious companions. Even the most brutal men recoil from something unfamiliar they sense in their wives, something they cannot fully comprehend but feel it as a latent danger. This is what drives the man to constant caution in his relationship with woman. And, in trying to establish some kind of balance with their female partner, their reaction is violence.

Mythical Lilith The singular story of Lilith, as we know it today, never existed in the

world mythology. Individual texts about demoness of the night or the dark side of woman, which finally, after many centuries, embodied as a separate female entity named Lilith, were conceived in different parts of the world, in different epochs. And in spite of numerous transformations and metamor-phoses, this creature reincarnates the archetypal matrix of terrifying and dia-


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bolical aspect of femininity worldwide, known in the mythology of various nations as demoness, man-eater and murderer of infants [2].

In the apocryphal texts it can be found under various names, hidden behind different personages: as queen of Zamargada, queen of Sheba, Ser-pent from the Garden of Eden, which led Eve and, consequently, Adam into sin, Kali, Hecate, Morgan le Fay, Lorelei, even Shakespeare’s Lady Macbeth in dramatic literature, and many other terrifying figures.

Two figures preceding Lilith and connected with her in the most ob-vious way, which we would like to emphasize, are the Babylonian demoness Lamashtu and her Greek version Lamia [3,4]. They are also mentioned in reference with eating men and murdering children. These two examples, as many others apart from Lilith, are the living proof of the existence of a fatal error incorporated at some point during the evolution of mankind, deeply hidden, that sometimes emerges in the form of radical evil, aimed against the natural mate and his children. This actual error is only a personified fact masked as a myth, so its existence could be brought closer to the ordinary man.

Interpretations of Lilith are numerous and controversial, but the best known are undoubtedly those of Lilith as the first Eve, originating from the II century Midrash, which is a form of active contemplation or meditation on the subject of biblical tradition, particularly the first and second Book of Genesis, where two contradictory versions of the creation of man are found [5]. According to one of them, man and woman were created at the same time, virtually out of nothing or out of earthly dust, in God’s image, and ac-cording to the other version, the creation of Eve was preceded by the creation of Adam alone. As we know, orthodox Jews and Christians accepted the sec-ond version as the official credo of the religion [6].

The first written account of the existence of Lilith as Adam’s first wife was given in a commentary known as Alphabet ben Sira, believed to have originated between VII and X century AD [7]. Later this idea developed further, reaching its peak in the XIII century, in the Kabbalah, particularly in the classic text of Jewish mysticism known as Zohar [8]. Thus, as opposed to the Old Testament, which refers only to Eve as Adam’s first wife, in the rab-binical literature another woman was mentioned for the first time, as Adam’s first companion, before God’s creation of Eve, and who, in the Jewish folk-lore, is known by the name of Lilith. She believed that, since they were cre-ated at the same time, from the dust of the earth, that is, from the same matter and by the same Creator, man and she should be equal in all. But Adam did not accept this explanation, following the advice of the Creator, and contin-ued to demand submission and absolute obedience, claiming that he, as the image of Elohim, was her master and owner. Her standing up against the in-justice was fundamentally right, but it was carried out in the wrong way, and she condemned herself beforehand to be the loser, by confronting the oppo-nent too strong for her. However, the rage she felt at that moment blurred her


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mind and she resorted to irrational behavior. In a moment, she uttered the Ineffable Name, spread her wings and disappeared in the sky, fleeing to the demons, to the Red Sea, where she stayed and married Samael, the blind de-mon king, and became the queen and mother of demons.

God sends three angels to bring her back, which she refuses, and she is then horribly punished - to losing one hundred of her children every day. Standing above the bodies of her dead children, with tearless eyes, she vows to eternal revenge over Adam, that from that moment on, she would kill all his children and his children’s children, as long as mankind exists, for she is immortal. Subsequently, in the answer to Adam’s pleading, God creates Eve from Adam’s rib, as a symbolic act of woman’s submission to man, in order to avoid the repetition of the first conflict and the dilemma regarding su-premacy and domination. Adam is, therefore, the principal human being, and Eve comes later from a part of his body, to be obedient to her man and to be-long to him [9].

By leaving Adam and the Garden of Eden, Lilith has embarked on a long journey of eternal retribution, never completely satisfied and therefore repetitive, for the humiliation she had experienced as the first wife from the one chosen for her by God. According to all descriptions, regardless of their source or religious origin, she embodies the fundamental connection between female and demonic, in other words, the fatal dimension undividable from femininity, with the basic intent to negate the alleged perfection and suprem-acy of the male aspect of human beings.

Psychology of woman Referring to the psychology of woman, certain aspects can already be

detected in Zohar, referring to Lilith as the Prostitute, the Damned, the Sinful or the Black, and warning men to be careful at all times, since every woman, even a daughter of Eve, carries within herself the hidden powers of Lilith, in her part of anima [8]. So, on the one hand there is Eve, representing the pa-rental-instinctive aspect of the female principle, protecting, nurturing, a sym-bol of life, and Lilith on the other, her complete opposite, vindictive, evil and potentially fatal. She is the dark aspect of female sexuality, oceanic and ar-chetypal femininity in the naked form; we have to stress that she is more of an idea of an aspect of female nature than the real nature of woman. In the light of Jung’s analytic psychology, she is a part of the dark side of Anima, in constant conflict with the divine and unchangeable order that degrades the woman to useful animalism and the means for male pleasure [10].

This duality of female nature is the most obvious in the menstrual cycle. In the first half, Eve is the stronger one. Waiting for the ovulation and possible conception, the woman feels open, receptive and connected with the world and the life. If the conception does not occur, Eve draws back and Li-lith takes over. Hope turns into despair. Generally speaking, the powers of Lilith are at their highest during the most important turning points in the life


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of woman: in puberty, beginning and end of pregnancy, maternity and meno-pause.

When pathology is considered, Lilith could be responsible for early and late gestoses, spontaneous miscarriages, PMS, postpartum psychoses and depressions, infanticide etc. She is also a personification of inexplicable events and phenomena occurring in reality, such as nocturnal emissions or SIDS (Sudden Infant Death Syndrome), death of otherwise completely healthy babies during sleep, which is still of unknown etiology.

There are numerous questions based on sound reasoning, and Lilith eludes them all and remains the unreachable aspect of the dark side of woman, with no counterpart in the male pandemonium. By the amount of evil he possesses inside, the only one similar to her could be Asmodeus, the son of Naamah and Shamdon, demon and spirit instigating such lust in men that they cannot resist and be disloyal to their spouses, always prepared to kill any man who presents an obstacle in conquering women [3]. The demon, of Persian origin, appearing also in the Hebrew mythology, was the embodiment of evil energy and terror. Or, in the literature, perhaps the dark Heathcliff.

It is possible that the ambiguous and polysemantic personality of Li-lith, the queen and mother of demons, clearly distinguishable, rising above her entire mythical suite, is, in the psychoanalytical sense, the product of an outstanding symbolic condensation. She is an imaginary and synthetic merger of various, sometimes contradictory assumptions or representations, pointing to different archetypal beings, the matrixes of which we carry inside ourselves, without being aware of it.

Finally, a discrete feature of this mythical woman is perhaps none the less significant, when deliberating on the motives of her behavior. In the depths of her soul, Lilith is a woman who has experienced disappointment and defeat in love, or in her desire to achieve motherhood with the man she loved; because in the beginning her love for Adam was indeed selfless and strong, and she could not have known any other man except Adam, who had somehow offended and humiliated her, unforgivably. And this disappoint-ment, without forgiveness, can perhaps explain many things. From the very beginning, she never acts as a fighter who is trying to regain her place beside the man she loves, but only as a cruel avenger. The unquenchable thirst for revenge is her only spiritual feature. Could this be a sign of her primal weak-ness and fear of defeat should she enter into an open confrontation with man, or of the failed attempt to make peace with him? The fear of losing the battle with Eve, who suppressed her by her own fault, darkens her noetic horizon and turns her into irrational evil, without any limits or scruples.

Basically, conflict with the children is always a shifted conflict with their father, the successor of Adam’s bloodline. Killing of children, who are the natural prolongation of life, and destruction of male semen through noc-turnal emissions, is actually a fight against the continuation of life in a wider sense. In this way, the evil of Lilith is even more deadly and goes even fur-


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ther, and she becomes even more terrifying and ominous in her infernal in-tent, because she fights not only against mankind, but also against the very Creator of life, and, ultimately, the life itself.

In spite of numerous intellectual speculations on the nature of Lilith, following more or less their own logic, we still cannot be fully satisfied by our understanding of the origin of motives for the mysterious Lilith’s behav-ior. We are compelled to return to the same question over and over again: why did Lilith renounce her femininity so easily, in all aspects, and kept only her demonic side, unusually similar to Shakespeare’s lady Macbeth? Unques-tionably and eternally. Why did she back away before Eve and let her take over the role of Great mother and wife of Adam, although originally the Creator bestowed this role on her? To be the ancient mother of mankind? Her primal rivalry with the newly-created Eve, made by the same Creator who first made her, is nowhere to be seen. Why did she renounce her mother-hood? Out of pride or hurt feelings, keeping only her driving sexual and vin-dictive aspect, since sexuality and passionate aggression are two very close psychological categories, which easily transform into one another and ex-change their energy?

Significance for psychopathology Lilith is present in the modern times, living and active, because she is

the only deity destined to live to the Judgment day. Even today, she is still the dark and destructive aspect of woman, equally dangerous for men, women and children. As a matter of fact, the Jews today are more often try-ing to rehabilitate her and sublimate her evil into the feministic aspect, repre-senting her as a champion of women’s rights, whose behavior is reactive in origin and comes as a result of the insult she received from Man. We cannot be sure if this effort would succeed. We see it only as an awkward attempt at her rehabilitation, because even today she appears as a malevolent spirit, and a frequent guest in psychopathology and psychiatrists’ offices, which makes her an existing evil.

Lilith-mother is fairly known to psychotherapists and their patients, her victims being her children, husbands, lovers or female rivals. In this field, Lilith can appear as seductress of her male children, the cause of their being in love with their mothers, the culprit for homosexual deviations or impo-tence of her sons. Lilith can seduce husbands of her daughters and thus have vengeance over the mythical Eve, by taking their husbands from them. She makes the husbands spill their semen at night, thus destroying their offspring.

Mother-Lilith, or the one who gives birth to demon children, de-serves her own special nosographic mark in modern psychopathology, since she is ubiquitous and represents permanent danger. And she also exists, to a certain extent and carefully hidden, in the Shadow of every woman. Al-though she comes from a myth, her presence in everyday life and in psycho-pathology is so strong that she should also have her place and name among


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the numerous entities, such as the Lilith complex, similar to the Oedipus or Electra complex, or the Don Juan complex.

It is also possible that the story of Lilith tries to relate and symbolize the opposition against the male order, which even regulates “proper” func-tioning of the Universe. Not only that we will see her as Lilith, the first wife of Adam, rebelling against the obligation imposed on her by the Ruler of all things, to stay beneath the man, but we will also see her as gaining the oppor-tunity to rise to the “heights of the Universe”, thus taking the advantage of the rise, whose wing and vertical ascent were up to that moment metaphori-cally kept exclusively for the man. Perhaps her destructiveness was, in a de-viated way, understood as her difficult to grasp hermetic message. In the modern times of fragile balance between sensuality and spirituality, the se-ductive and prolific Lilith offers herself as a timeless dimension between the constant threat of retreating and the sometimes twisted glorification of reason.

References 1. Koltuv BB. The book of Lilith. York Beach. ME: Nicolas-Hays;

1986. 2. Farrar JS. The Witches’ Goddess: The feminine principle of divin-

ity. London: Robert Hale; 1995. 3. Hajat VČ, Džozef V. Demoni. Beograd: Ateneum; 1996. 4. Graves R. The Greek myths. New York: Penguin Books; 1960. 5. Dan J. The Hebrew story in the Middle Ages. Jerusalem; 1974. 6. Milgrom J. Some second thoughts about Adam’s first wife. In Gene-

sis 1-3 in the History of Exegesis, ed. G. Robbins. Lewiston. ME: Edwin Mellen; 1988.

7. Yassif E. Sippurey ben Sira be-yame ha Binayyim [The Tales of Ben Sira in the Middle Ages]. Jerusalem: Magnes Press; 1984.

8. Matt DC. Zohar: The book of enlightenment. New York: Paulist Press; 1983.

9. Ausbel N. A treasury of Jewish folklore. New York: Bantam; 1980. 10. Jung GK. Dinamika nesvesnog. Novi Sad: Matica srpska; 1996.

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Nataša PETROVIĆ STEFANOVIĆ, specijalista medicinske psihologije, Institut za mentalno zdravlje, Beograd, Srbija i Crna Gora

Natasa PETROVIC STEFANOVIC, medical psychology specialist, Institute of Mental Health, Belgrade, Serbia and Montenegro


Psihijat. dan. /2005/37/2/349-352/ Obaveštenja

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IZMENE MADRIDSKE DEKLARACIJE I DODATNA UPUTSTVA

U SPECIFIČNIM ETIČKIM SITUACIJAMA∗

MADRIDSKA DEKLARACIJA (jun 2005) Svetsko udruženje psihijatara usvojilo je 1977. godine Havajsku dekla-

raciju u kojoj su data etička uputstva za psihijatrijsku praksu. Deklaracija je do-punjena u Beču 1983. godine. Da bi odrazilo uticaj promene društvenih stavova i novih medicinskih dostignuća na psihijatriju, Svetsko udruženje psihijatara je još jednom izvršilo reviziju etičkih standarda kojih bi trebalo da se pridržavaju svi njegovi članovi i sve osobe koje se praktično bave psihijatrijom.

Medicina je istovremeno i isceliteljska veština i nauka. Dinamika ove kombinacije najbolje se ogleda u psihijatriji, grani medicine koja je specijalizo-vana za negu i zaštitu onih koji su bolesni ili nemoćni usled mentalnog poreme-ćaja ili oboljenja. Iako postoje kulturne, društvene i nacionalne razlike, potreba za moralnim ponašanjem i neprestanim preispitivanjem etičkih standarda je uni-verzalna.

Kao lekari, psihijatri moraju biti svesni etičkih implikacija svog poziva, kao i specifičnih etičkih zahteva vezanih za psihijatriju. Kao članovi društva, psihijatri se moraju zalagati za pravedno i ravnopravno postupanje prema men-talno obolelima, za socijalnu pravdu i ravnopravnost.

Etičnost se zasniva na individualnom osećanju odgovornosti psihijatra prema pacijentu i na njegovoj proceni pravilnog i odgovarajućeg ponašanja. Spoljašnji standardi i uticaji, kao što su kodeksi profesionalnog ponašanja, nauka o moralu ili zakonodavstvo, ne mogu sami po sebi biti garancija etičnosti u me-dicini. Psihijatri uvek moraju imati na umu granice koje postoje u odnosu izme-đu psihijatra i pacijenta, i da se, pre svega, rukovode poštovanjem pacijenata i brigom za njihovu dobrobit i integritet.

Upravo u ovom duhu, Generalna skupština Svetskog udruženja psihija-tara usvojila je 25. avgusta 1996. a dopunila 8. avgusta 1999. i 26. avgusta 2002. godine, sledeće etičke standarde, kojima bi trebalo da se rukovode psihijatri ši-rom sveta.

1. Psihijatrija je medicinska disciplina koja se bavi prevencijom men-

talnih poremećaja stanovništva, obezbeđivanjem najboljeg mogu-ćeg lečenja mentalnih poremećaja, rehabilitacijom osoba koje pate od mentalnih oboljenja i unapređenjem mentalnog zdravlja. Duž-nost psihijatra je da pruži pacijentu najbolju terapiju koja postoji, u skladu sa prihvaćenim naučnim saznanjima i etičkim principima.

∗ Izmene prihvaćene na Generalnoj skupštini Svetskog udruženja psihijatara, održanoj u Kairu 12. septembra 2005. godine


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Psihijatri bi trebalo da primenjuju terapijske intervencije koje u najmanjoj meri ograničavaju slobodu pacijenta, i da potraže savet u onim oblastima rada koje ne spadaju u njihovu osnovnu struku. Pri tome bi trebalo da vode računa o ravnopravnoj raspodeli sredstava u zdravstvu.

2. Dužnost psihijatra je da ide u korak sa naučnim dostignućima u svojoj oblasti i da nova saznanja prenosi i drugima. Psihijatri edu-kovani za istraživački rad treba da streme proširivanju naučnih gra-nica u psihijatriji.

3. Pacijent ima pravo da bude prihvaćen kao partner u terapijskom procesu. Odnos između psihijatra i pacijenta mora biti zasnovan na uzajamnom poverenju i poštovanju, kako bi pacijent mogao, na os-novu dobijenih informacija, slobodno da donese odluku. Dužnost psihijatara je da pacijentu pruže sve relevantne informacije, kako bi bio u stanju da donese racionalnu odluku, u skladu sa ličnim vred-nostima i sklonostima.

4. Kada je usled mentalnog poremećaja pacijent teško hendikepiran, onesposobljen i/ili nesposoban da pravilno rasuđuje, psihijatri bi trebalo da se konsultuju sa porodicom i, ako je potrebno, potraže pravni savet radi zaštite ljudskog dostojanstva i zakonskih prava pacijenta. Nijedno lečenje ne bi trebalo da se sprovodi protiv volje pacijenta, osim kada bi njegovo nesprovođenje ugrozilo život paci-jenta i/ili drugih osoba. Lečenje uvek mora biti u najboljem interesu pacijenta.

5. Kada se od psihijatara traži da izvrše procenu neke osobe, njihova je dužnost da joj prvo daju informacije i savet u vezi sa ciljem in-tervencije, načinom na koji će rezultati biti iskorišćeni, i mogućim posledicama izvršene procene. Ovo je naročito važno kada su psihi-jatri uključeni kao treća strana.

6. Informacije dobijene u terapijskom odnosu su poverljive, spadaju u privatnost pacijenta i trebalo bi ih koristiti samo i isključivo u cilju poboljšanja mentalnog zdravlja pacijenta. Psihijatrima se zabranju-je upotreba ovih informacija iz ličnih razloga ili radi lične koristi. Kršenje principa o poverljivosti informacija dozvoljeno je jedino u slučaju kada to zakon zahteva (npr. obavezno prijavljivanje zlostav-ljanja dece) ili kada bi zbog poštovanja poverljivosti informacija te-lesno ili duševno zdravlje pacijenta ili treće osobe moglo biti ozbilj-no ugroženo; psihijatri bi, kad god je to moguće, trebalo prvo da obaveste pacijenta o postupcima koji će se preduzeti.

7. Istraživanja koja se ne sprovode u skladu sa naučnim standardima i koja nisu validna sa naučne tačke gledišta, nisu moralna. Istraživač-ke aktivnosti treba da odobri odgovarajući etički komitet. Psihijatri bi trebalo da slede međunarodna i nacionalna pravila za sprovođe-nje istraživanja. Istraživanja treba da sprovode ili da njima rukovo-de jedino osobe koje za to imaju odgovarajuću edukaciju. Pošto psihijatrijski pacijenti predstavljaju posebno ranjivu populaciju is-


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pitanika, mora se pokloniti posebna pažnja proceni njihove sposob-nosti da učestvuju u istraživanju, i zaštiti njihove slobodne volje i duševnog i telesnog integriteta. Etičke standarde bi, takođe, trebalo primenjivati prilikom odabira populacionih grupa u svim vrstama istraživanja, uključujući epidemiološka i sociološka istraživanja, kao i kolaborativna istraživanja koja uključuju druge discipline ili više istraživačkih centara.

NOVA POSEBNA UPUTSTVA – DODATAK MADRIDSKOJ DEKLARACIJI

Zaštita prava psihijatara (30. jun 2005)

1. Psihijatri moraju da štite svoje pravo da, prema zahtevima struke i

očekivanjima javnosti, leče svoje pacijente i da se zalažu za njihovu dobrobit.

2. Psihijatri treba da imaju pravo da se bave svojom strukom na najvi-šem nivou, pružajući nezavisne procene mentalnog stanja osobe i uspostavljajući efikasne protokole lečenja i praćenja u skladu sa najboljom praksom i medicinom zasnovanom na dokazima.

3. Postoje neki aspekti u istoriji psihijatrije, ali i uslovi rada u nekim današnjim totalitarnim političkim režimima i ekonomskim sistemi-ma vođenim profitom, koji pojačavaju opasnost od zloupotrebe psi-hijatrije, u smislu da su psihijatri primorani da pristanu na neprik-ladne zahteve i daju netačne psihijatrijske izveštaje koji idu na ruku sistemu, ali štete interesima osobe čije se stanje procenjuje.

4. Psihijatri su takođe stigmatizovani kao i njihovi pacijenti i, slično njima, mogu postati žrtve diskriminacije. Psihijatri treba da imaju pravo i obavezu da se bave svojom strukom i da se zalažu za medi-cinske potrebe i društvena i politička prava svojih pacijenata, a da zbog toga ne trpe odbacivanje kolega, ismevanje u medijima i pro-gon.

SAOPŠTAVANJE DIJAGNOZE ALCHAJMEROVE BOLESTI I DRUGIH DEMENCIJA (30. jun 2005)

Pacijent ima pravo da zna da boluje od Alchajmerove bolesti, i to pravo

je sada postavljeno kao prioritet koji zdravstveni radnici priznaju i prihvataju. Većina pacijenata želi da dobije sve raspoložive informacije i da bude aktivno uključena u donošenje odluka u vezi sa lečenjem. U isto vreme, pacijenti imaju pravo i da ne znaju, ako je to njihova želja. Svima se mora pružiti mogućnost da saznaju ili ne saznaju onoliko koliko žele.


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Promene u kogniciji pacijenta ugrožavaju njegovu sposobnost rasuđiva-nja i shvatanja. Takođe, pacijenti sa demencijom često dolaze u pratnji članova porodice, što u odnos između lekara i pacijenta uvodi i treću stranu.

Svi doktori, pacijenti i porodice, koji godinama međusobno dele odgo-vornost za borbu protiv Alchajmerove bolesti, moraju imati pristup informaci-jama o ovoj bolesti, uključujući i dijagnozu.

Osim što je to njegovo pravo, informisanost pacijenta može biti od više-struke koristi. Pacijentima i/ili porodicama trebalo bi saopštiti dijagnozu u što ranijoj fazi bolesti. Veoma je korisno ako su članovi porodice (ili nezvanični pružaoci nege) uključeni u razgovor prilikom saopštavanja dijagnoze.

Lekar treba da pruži precizne i pouzdane informacije, koristeći jednos-tavne izraze. Takođe bi trebalo da proceni u kojoj meri pacijent i porodica razu-meju situaciju. Kao i obično, posle loše vesti trebalo bi pružiti informacije o da-ljim planovima za lečenje. Treba pružiti obaveštenja o fizikalnoj terapiji ili tera-piji govora, o grupama za podršku, centrima za dnevni boravak i drugim inter-vencijama. Takođe bi trebalo naglasiti da reorganizovana porodična mreža može znatno olakšati teret pružaoca nege i održati kvalitet života koliko god je to mo-guće.

Postoje neki izuzeci, od kojih su neki privremeni, kada je reč o saopšta-vanju dijagnoze pacijentu sa demencijom: 1) teška demencija, kada pacijent naj-verovatnije ne bi razumeo dijagnozu, 2) kada je verovatno da bi se javila fobija od tog stanja, ili 3) kada je pacijent u stanju teške depresije.

Dvostruka odgovornost psihijatara (30. jun 2005)

Ovakve situacije se mogu javiti tokom zakonskog postupka (npr. spo-

sobnost pacijenta da bude podvrgnut sudskom procesu, krivična odgovornost, opasnost, sposobnost svedočenja na sudu) ili drugih postupaka vezanih za potre-bu da se utvrdi sposobnost, kao npr. za potrebe osiguranja, radi procene zahteva za olakšice, ili za potrebe zaposlenja, kada se procenjuje radna sposobnost ili podobnost za obavljanje određenog posla ili posebnog radnog zadatka.

U toku terapijskih interakcija može doći do konfliktnih situacija ako in-formacije koje psihijatar ima o pacijentovom stanju ne mogu ostati poverljive, ili kada su kliničke beleške ili medicinska dokumentacija deo većeg dosijea radni-ka, pa prema tome nisu namenjene samo kliničkom osoblju zaduženom za slučaj (npr. u vojsci, zatvorskim sistemima, medicinskim službama za zaposlene u ve-ćim korporacijama u protokolima lečenja koje plaća treća osoba).

Kada se prilikom procene stanja neke osobe psihijatar suočava sa dvos-trukim obavezama i odgovornostima, dužan je da tu osobu obavesti o prirodi ovakvog triangularnog odnosa i odsustva terapijskog odnosa između lekara i pacijenta, pored obaveze da podnese izveštaj trećoj strani, čak i kada su rezultati negativni i mogli bi da štete interesima osobe nad kojom se vrši procena. Pod ovakvim okolnostima, osoba može odlučiti da ne nastavi sa procenom.

Pored toga, psihijatri bi trebalo da se zalažu za razdvajanje podataka i za ograničenja pri saopštavanju informacija, kako bi samo elementi koji su neop-hodni za svrhe organizacije mogli da budu otkriveni.

Psihijat. dan. /2005/37/2/353-356/ Announcement

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ADJUSTMENTS OF THE MADRID DECLARATION AND ADDITIONAL SPECIFIC ETHICAL GUIDELINES∗

DECLARATION OF MADRID (June 2005)

In 1977, the World Psychiatric Association approved the Declaration of Hawaii which set out ethical guidelines for the practice of psychiatry. The Dec-laration was updated in Vienna in 1983. To reflect the impact of changing social attitudes and new medical development on the psychiatric profession, the World Psychiatric Association has once again undertaken a review of ethical standards that should be abided to by all its members and all persons practicing psychiatry.

Medicine is both a healing art and a science. The dynamics of this com-bination are best reflected in psychiatry, the branch of medicine that specializes in the care and protection of those who are ill or infirm, because of a mental dis-order or impairment. Although there may be cultural, social and national differ-ences, the need for ethical conduct and continual review of ethical standards is universal.

As practitioners of medicine, psychiatrists must be aware of the ethical implications of being a physician, and of the specific ethical demands of the spe-cialty of psychiatry. As members of society, psychiatrists must advocate for fair and equal treatment of the mentally ill, for social justice and equity for all.

Ethical practice is based on the psychiatrist’s individual sense of respon-sibility to the patient and judgment in determining what is correct and appropri-ate conduct. External standards and influences such as professional codes of conduct, the study of ethics, or the rule of law by themselves will not guarantee the ethical practice of medicine. Psychiatrists should keep in mind at all times the boundaries of the psychiatrist-patient relationship, and be guided primarily by the respect for patients and concern for their welfare and integrity.

It is in this spirit that the World Psychiatric Association approved at the General Assembly on August 25th, 1996, amended on August 8th, 1999 and on August 26th, 2002 the following ethical standards that should govern the practice of psychiatrists universally.

1. Psychiatry is a medical discipline concerned with the prevention of mental disorders in the population, the provision of the best possible treatment for mental disorders, the rehabilitation of individuals suf-fering from mental illness and the promotion of mental health. Psy-chiatrists serve patients by providing the best therapy available con-sistent with accepted scientific knowledge and ethical principles. Psychiatrists should devise therapeutic interventions that are least

∗ Adjustments were approved at the World Psychiatric Association General Assembly, held in Cairo, September 12th, 2005


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restrictive to the freedom of the patient and seek advice in areas of their work about which they do not have primary expertise. While doing so, psychiatrists should be aware of and concerned with the equitable allocation of health resources.

2. It is the duty of psychiatrists to keep abreast of scientific develop-ments of the specialty and to convey updated knowledge to others. Psychiatrists trained in research should seek to advance the scien-tific frontiers of psychiatry.

3. The patient should be accepted as a partner by right in the therapeu-tic process. The psychiatrist-patient relationship must be based on mutual trust and respect to allow the patient to make free and in-formed decisions. It is the duty of psychiatrists to provide the pa-tient with all relevant information so as to empower the patient to come to a rational decision according to personal values and prefer-ences.

4. When the patient is gravely disabled, incapacitated and/or incompe-tent to exercise proper judgment because of a mental disorder, the psychiatrists should consult with the family and, if appropriate, seek legal counsel, to safeguard the human dignity and the legal rights of the patient. No treatment should be provided against the patient’s will, unless withholding treatment would endanger the life of the pa-tient and/or the life of others. Treatment must always be in the best interest of the patient.

5. When psychiatrists are requested to assess a person, it is their duty first to inform and advise the person being assessed about the pur-pose of the intervention, the use of the findings, and the possible re-percussions of the assessment. This is particularly important when psychiatrists are involved in third party situations.

6. Information obtained in the therapeutic relationship is private to the patient and should be kept in confidence and used, only and exclu-sively, for the purpose of improving the mental health of the patient. Psychiatrists are prohibited from making use of such information for personal reasons, or personal benefit. Breach of confidentiality may only be appropriate when required by law (as in obligatory reporting of child abuse) or when serious physical or mental harm to the pa-tient or to a third person would ensue if confidentiality were main-tained; whenever possible, psychiatrists should first advise the pa-tient about the action to be taken.

7. Research that is not conducted in accordance with the canons of sci-ence and that is not scientifically valid is unethical. Research activi-ties should be approved by an appropriately constituted ethics com-mittee. Psychiatrists should follow national and international rules for the conduct of research. Only individuals properly trained for re-search should undertake or direct it. Because psychiatric patients constitute a particularly vulnerable research population, extra cau-tion should be taken to assess their competence to participate as re-


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search subjects and to safeguard their autonomy and their mental and physical integrity. Ethical standards should also be applied in the selection of population groups, in all types of research including epidemiological and sociological studies and in collaborative re-search involving other disciplines or several investigating centres.

NEW SPECIFIC GUIDELINES APPENDED TO THE MADRID DECLARATION

Protection of the Rights of Psychiatrists (30 June 2005)

1. Psychiatrists need to protect their right to live up to the obligations

of their profession and to the expectations the public has of them to treat and to advocate for the welfare of their patients.

2. Psychiatrists ought to have the right to practice their specialty at the highest level of excellence by providing independent assessments of a person’s mental condition and by instituting effective treatment and management protocols in accordance to best practices and evi-dence-based medicine.

3. There are aspects in the history of psychiatry and in present working expectations in some totalitarian political regimes and profit driven economical systems that increase psychiatrists’ vulnerabilities to be abused in the sense of having to acquiesce to inappropriate demands to provide inaccurate psychiatric reports that help the system, but damage the interests of the person being assessed.

4. Psychiatrists also share the stigma of their patients and, similarly, can become victims of discriminatory practices. It should be the right and the obligation of psychiatrists to practice their profession and to advocate for the medical needs and the social and political rights of their patients without suffering being outcast by the profes-sion, being ridiculed in the media and persecuted.

DISCLOSING THE DIAGNOSIS OF ALZHEIMER’S DISEASE (AD) AND OTHER DEMENTIAS (30 June 2005)

AD patient’s right to know is now a well established priority, recognised

by healthcare professionals. Most patients want all information available and to be actively involved in making decisions about treatments. At the same time, patients have the right also not to know if that is their wish. All must be given the opportunity to learn as much or as little as they want to know.

The alteration of patient’s cognition makes the ability to make judg-ments and insight more difficult. Patients with dementia are also often brought by family members which introduces into the doctor-patient relationship a third partner.


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Doctors, patients and families who share the responsibilities for fighting and coping with Alzheimer’s disease for years all require access to information on the disease, including the diagnosis.

In addition to the “patient’s right to know”, telling the patient has many benefits. Patients and/or families should be told the diagnosis as early as possible in the disease process. Having family (or informal carer) involved in the discus-sion of the disclosure process is highly beneficial.

The physician should give accurate and reliable information, using sim-ple language. He also should assess the patient’s and the family’s understanding of the situation. As usual, the bad news should be accompanied by information on a treatment and management plan. Information on physical or speech therapy, support groups, day care centres, and other interventions should be provided. It should also be emphasised that a reorganised family network can alleviate the carer’s burden and maintain quality of life as far as possible.

There are some exceptions, some of them transitory, to the disclosure of the diagnosis to a patient with dementia: 1) severe dementia where understand-ing the diagnosis is unlikely, 2) when a phobia about the condition is likely, or 3) when a patient is severely depressed.

Dual Responsibilities of Psychiatrists (30 June 2005)

These situations may arise as part of legal proceedings (i.e. fitness to

stand trial, criminal responsibility, dangerousness, testamentary capacity) or other competency related needs, such as for insurance purposes when evaluating claims for benefits, or for employment purposes when evaluating fitness to work or suitability for a particular employment or specific task.

During therapeutic interactions conflicting situations may arise if the physician’s knowledge of the patient’s condition cannot be kept private or when clinical notes or medical records are part of a larger employment dossier, hence not confidential to the clinical personnel in charge of the case (i.e. the military, correctional systems, medical services for employees of large corporations, treatment protocols paid by third parties).

It is the duty of a psychiatrist confronted with dual obligations and re-sponsibilities at assessment time to disclose to the person being assessed the na-ture of the triangular relationship and the absence of a therapeutic doctor-patient relationship, besides the obligation to report to a third party even if the findings are negative and potentially damaging to the interests of the person under as-sessment. Under these circumstances, the person may choose not to proceed with the assessment.

Additionally, psychiatrists should advocate for separation of records and for limits to exposure of information such that only elements of information that are essential for purposes of the agency can be revealed.


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KALENDAR KONGRESA

2006.

14th Congress of the European Association for Psychotherapy July 13–16, 2006, London, Great Britain E-mail: [email protected] 2nd Biennial Regional Group Conference of the International Society for Bipolar Disorders August 2–4, 2006, Edinburgh, Scotland E-mail: [email protected] Website: http://www.kenes.com/isbd 3rd Congress of the Asian Association for Psychotherapy August 28–September 1, 2006, Tokyo, Japan E-mail: www.the-convention.co.jp/06icptj 3rd Annual International Mental Health at the IoP – People on the Move August 30 – September 1, 2006, London Website: www.iop.klc.ac.uk/international/conference E-mail: [email protected] 10th Congress of the European Federation of Neurological Societies September 2–5, 2006, Glasgow, Scotland Website: www.kenes.com/efns2006 E-mail: [email protected] 9th Conference of the International Association for the Treatment of Sexual Offenders – The Benefits of Sexual Offender Therapy September 6–9, 2006, Hamburg, Germany Website: http://www.iatso.org/Meetings/06hamburg 11th European Symposium on Suicide and Suicidal Behaviour – From Greenland to the Caucasus, from the Urals to Iberia September 9–12, 2006, Portorož, Slovenia Website: www.esssb11-slo.org E-mail: [email protected] 6th International Congress of Neuropsychiatry – The Coming of Age of Neuropsychiatry September 10–14, 2006, Sydney, Australia Website: www.inacongress2006.com E-mail: [email protected] Autism & ADHD Symposium September 12–14, 2006, Istanbul, Turkey Website: www.istanbulotizmsempozyumu.org E-mail: [email protected]

Psihijat. dan. /2005/37/2/357-375/ Obaveštenja 358

Zavod za psihofiziološke poremećaje i govornu patologiju “Prof. dr Cvetko Brajović” povodom 35 godina svoga postojanja organizuje međunarodni kongres sa temom “Multidisciplinarni pristupi u specijalnoj edukaciji i rehabilitaciji” Septembar 15–17, 2006, Beograd Website: www.zgp.org.yu Informacije: 011/3617–932 ili e-maila [email protected] 10th Anniversary Congress of Body-Psychotherapy Presented by the European Association for Body-Psychotherapy Bodies of Knowledge – Resources for a world in crisis September 21–24, 2006, Askov, Denmark Website: http://www.eabp.org/eabp2006.html E-mail: [email protected] VIII Anual Meeting of the International Society for Addiction Medicine – A World of Drugs, A Universe of Therapies September 27–30, 2006, Oporto, Portugal E-mail: [email protected] XV IFTA World Congress – Reflection, Resilience and Hope; Strengthening Foundations October 4–7. 2006, Reykjavík Iceland E-mail: [email protected] Website: http://www.ifta2006.org Udruženje za kliničku neurofiziologiju Srbije i Crne Gore, Medicinski fakultet Univerziteta u Beogradu, Institut za mentalno zdravlje Beograd Godišnji sastanak Udruženja za kliničku neurofiziologiju Srbije i Crne Gore sa međunarodnim učešćem Oktobar 5, 2006, Institut za mentalno zdravlje, Beograd E-mail: [email protected]; [email protected]; Adresa: Prof. dr Žarko Martinović, Institut za mentalno zdravlje, Odsek za epilepsije i kliničku neurofiziologiju, Palmotićeva 37, 11 000 Beograd European Workshop on Traumatic Stress October 5–6, 2006, Madrid, Spain Website: www.tilesa.es/ewots2006 E-mail: [email protected] Together Agaınst Stıgma – 3rd Internatıonal Conference – A Decade of Progress October 5–8, 2006, Istanbul, Turkey Website: www.stigmaistanbul.org E-mail: [email protected] 22nd Danube Symposion of Psychiatry – Psychiatry – today and tomorrow October 11–15, 2006, Albena Resort, Bulgaria Website: www.privatepsychiatry.org www.albena.bg E-mail: [email protected]


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International Conference on “Engaging the Other” – The Power of Compassion October 26–29, 2006, Kalamazoo, Michigan USA Website: www.cbiworld.org E-mail: [email protected] XIV World Congress on Psychiatric Genetics October 28 – November 1, 2006, Cagliari, Italy Website: www.wcpg2006.it E-mail: [email protected] [email protected] [email protected] 6th International Forum on Mood and Anxiety Disorders November 29 – December 1, 2006, Vienna Website: http://www.aim-internationalgroup.com/2006/ifmad E-mail: [email protected] 1st International Symposium on Therapeutic in Psychiatry – Solving Problems in Clinical Practice: Schizophrenias November 30 – December 1, 2006, Barcelona, Spain Website: www.geyseco.com/terapeutica.htm E-mail: [email protected] The Second Dual Congress on: Psychiatry and the Neurosciences 1st European Congress of the International Neuropsychiatric Association 2nd Mediterranean Congress of the World Federation of Societies of Biological Psychiatry December 7–10, 2006, Athens, Greece E-mail: [email protected], [email protected] Website: www.ina-wfsbp-dualcongress.gr IX IRCT International Symposium on Torture – Providing Reparation and Treatment, Preventing Impunity December 9–10, 2006, Berlin, Germany Email: [email protected] Website: www.irct.org

2007.

European Symposium – Psychiatry – Psychology – Psychotherapy Similarities and Differences February 16, 2007, Vienna, Austria E-mail: [email protected] Website: www.psychotherapy.org.uk 2nd International Congress on Health and Work Cuba 2007 March 12–16 2007, Havana, Cuba E-mail: [email protected] 15th European Congress of Psychiatry March 17–21, 2007, Madrid, Spain Website: http://www.kenes.com/aep2007 E-mail: [email protected]


World Psychiatric Association Regional Meeding International Psychiatrists on African Safari March 21–23, 2007, Nairobi Website: www.wpa2007nairobi.com 2nd International Congress of Biological Psychiatry April, 17–21, 2007, Santiago de Chile Website: www.wfsbp.org www.wfsbp-santiago2007.org E-mail: [email protected] 6th European Conference of the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO) – Nursing Communication in Multidisciplinary Practice April 19–21, 2007, Amsterdam The Netherlands Website: http://www.acendio.net E-mail: [email protected] XIV International Symposium about Current Issues and Controversies in Psychiatry – Risk Factors in Psychiatry April 26–27, 2007, Barcelona, Spain Website: geyseco.com/controversias.htm E-mail: [email protected] Conflict, Mental Health and Making the Peace May 11–12, 2007, Lymassol, Cyprus E-mail: [email protected] 15th World Contress of the World Association for Dynamic Psychiatry – What is New in Psychiatry and Psychotherapy? Creative Dimensions in Modern Treatment May 15.18, 2007, St Petersburg, Russia Website: http://www.wadp-congress.de E-mail: [email protected] 10th European Conference on Traumatic Stress June 5–9, 2007, Opatija, Croatia Website: www.ecots2007.com E-mail: [email protected] 7th World Congress on Brain Injury of the International Brain Injury Association (IBIA) June 17–21, 2007, Jerusalem, Israel E-mail: [email protected] Website: www.kenes.com/ibia07 13th International Headache Congress June 28 – July 1, 2007, Stockholm, Sweden E-mail: [email protected]


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International Conference on Stress August 23–26, 2007 Budapest, Hungary Website: www.stress07.com E-mail: [email protected] 13th International Congress – Bridging the Gaps (Integrating Perspectives in Child and Adolescent Mental Health) August 25–29, 2007, Florence, Italy Website: www.escap-net.org E-mail: [email protected] X International ISSPD (International Society for the Study of Personality Disorders) Congress September 19–22, 2007, The Hague, The Netherlands Website: www.isspdcongress2007.nl Globalization and Psychiatry September 20–23, 2007, Shanghai, China Website: www.wpa2007shanghai.com The International Society on Brain and Behaviour 3rd International Congress on Brain and Behaviour (3rd ICBB) November 29 – December 2, 2007, Thessaloniki, Greece Deadlines: Abstract submission: March 1st, 2007 Website: http://www.psychiatry.gr/ E-mail: [email protected], [email protected]

2008.

XIV World Congress of Psychiatry, hosted by the Czech Psychiatric Association September 19–25, 2008, Prague, Czech Republic Contact: Dr. Jiri Raboch E-mail: [email protected]

2009.

9th World Congress of Biological Psychiatry June 28–July 2, 2009, Paris, France

2011. XV World Congress of Psychiatry, hosted by the Argentina Association of Psychiatrist (AAP), the Association of Argentinean Psychiatrists (APSA), and the Foundation for Interdisciplinary Investigation of Communication (FINTECO) August or September 2011, Buenos Aires, Argentina Contact: Mariano R. Castex E-mail: [email protected] Website: www.congresosint.com.ar


WPA Scientific Meetings Professor Pedro Ruiz, Secretary for Meetings Professor and Vice Chairman University of Texas Medical School at Houston 1300 Moursund Street, Houston, TX 77030, USA Tel: +1 713 500 2799, Fax: +1 713 500 2757 E-mail: [email protected] WPA SPONSORED INTERNATIONAL CONGRESS (Zone 8) Title: “WPA International Congress” Place: Istanbul, Turkey Date: July 12–16, 2006 Organizer: a) Psychiatric Association of Turkey

b) Turkish Neuropsychiatric Society Contact: Dr. Levent Kuey E-mail: [email protected] Website: www.wpa2006istanbul.org WPA CO-SPONSORED CONFERENCE (Zone 3) Title: “Symposium on Roles de Avanzada para el

Psicoterapeuta ante la Violencia Global” Place: San Juan, Puerto Rico Date: September 2, 2006, 2006 Organizer: Wizards Continuing Education Contact: Dr. Victor Llado E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 5) Title: “VIII Argentinean Congress of Neuropsychiatry, IV

Latin American Congress of Neuropsychiatry and IX Alzheimer’s Disease Meeting”

Place: Buenos Aires, Argentina Date: September 5–8, 2006 Organizer: “Asociacion Neuropsiquiatrica Argentina” Collaboration: International Neuropsychiatric Association Contact: Leandro Tortora E-mail: [email protected] Website: www.neuropsiquiatria.org.ar WPA CO-SPONSORED CONFERENCE (Zone 8) Title: “Urban Areas and Mental Health International

Conference” Place: Bologna, Italy Date: September 19, 2006 Organizer: Italian Psychiatric Association Collaboration: WPA Section on Urban Mental Health Contact: Dr. Mariano Bassi E-mail: [email protected]


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WPA CO-SPONSORED CONFERENCE (Zone 3) Title: “Conferencia: Integracion Psiquiatrica y

Biopsychosocial Dentro del Humanismo” Place: Merida, Mexico Date: September 21–23, 2006 Organizer: Federacion Latinoamercana de Psiquiatria Biologica Collaboration: a) Mexican Psychiatric Association

b) Mexican Society of Neurology & Psychiatry Contact: Dr. Claudio Garcia Barriga E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 8) Title: “A World of Drugs, A Universe of Treatments” Place: Oporto, Portugal Date: September 26–30, 2006 Organizer: International Society of Addiction Medicine (ISAM) Contact: Dr. Antonio Pacheco Palha E-mail: [email protected] Website: www.isamweb.org WPA CO-SPONSORED CONFERENCE (Zone 5) Title: “VI World Congress of Depressive Disorders” and

“International Symposium on Addictive Disorders” Place: Mendoza, Argentina Date: September 27–30, 2006 Organizer: Dr. Jorge Nazar Collaboration: a) “Instituto de Neurosciencias y Humanidades

Medicas” b) “Universidad Nacional de Cuyo”

Contact: Dr. Jorge Nazar E-mail: [email protected] Website: www.mendoza2006.0rg WPA CO-SPONSORED CONFERENCE (Zone 9) Title: “National Conference on Psychiatry” Place: Craiova, Romania Date: September 28–October 1, 2006 Organizer: Romanian Psychiatric Association Contact: Dr. Tudor Udristoiu E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 8) Title: Third International Conference “Together Against

Stigma” Place: Istanbul, Turkey Date: October 5–8, 2006 Organizer: Psychiatric Association of Turkey Collaboration: Medical School of Istanbul Contact: Aslihan Polat E-mail: [email protected] Website: www.stigmaistanbul.org


WPA CO-SPONSORED CONFERENCE (Zone 17) Title: “Pacific Rim College of Psychiatrists Congress” Place: Taipei, Taiwan Date: October 6–8, 2006 Organizer: Pacific Rim College of Psychiatrists Contact: Dr. Allan Tasman E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 9) Title: “9th World Congress of Psychosocial Rehabilitation” Place: Athens, Greece Date: October 12–15, 2006 Organizer: World Association for Psychosocial Rehabilitation Contact: Dr. Michael Madianos E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 16) Title: “International Conference on Schizophrenia” Place: Chennai (Old Madras), India Date: October 13–15, 2006 Organizer: Schizophrenia Research Foundation Collaboration: World Health Organization Contact: Dr. R. Thara E-mail: [email protected] Website: www.scarfindia.org

www.icons-scarf.org WPA CO-SPONSORED CONFERENCE (Zone 8) Title: “Annual Congress, Spanish Society of Psychiatry” Place: Sevilla, Spain Date: October 16–21, 2006 Organizer: Spanish Society of Psychiatry Contact: Dr. Jose Giner E-mail: [email protected] Website: www.wpanet.org/meetings/m2006.doc WPA SPONSORED SECTION MEETING (Zone 8) Title: “8th World Congress of the International Psycho-

oncology Society” Place: Venice, Italy Date: October 18–21, 2006 Organizer: WPA Section on Psycho-oncology Collaboration: International Psycho-oncology Society Contact: Dr. Carlo L. Cazzullo E-mail: [email protected]


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WPA CO-SPONSORED CONFERENCE (Zone 3) Title: “XXIV APAL Congress” Place: Santo Domingo, Dominican Republic Date: November 1–4, 2006 Organizer: Latin American Psychiatric Association (APAL) Collaboration: Dominican Society of Psychiatry Contact: Dr. Cesar Mella E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 1) Title: “56th Annual Meeting of the Canadian Psychiatric

Association” Place: Toronto, Ontario, Canada Date: November 9–12, 2006 Organizer: Canadian Psychiatric Association Contact: Dr. Alex Saunders E-mail: [email protected] Website: www.cpa-apc.org WPA CO-SPONSORED CONFERENCE (Zone 8) Title: “XI Meeting in Bipolar Disorders” Place: Lisbon, Portugal Date: November 10–11, 2006 Organizer: WPA Section on Private Practice Collaboration: Portuguese Society of Psychiatry and Mental Health Contact: Professor Maria Luisa Figueira E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 11) Title: “Annual Meeting, Egyptian Psychiatric Association” Place: Alexandria, Egypt Date: November 15–17, 2006 Organizer: Egyptian Psychiatric Association Contact: Dr. Tarek Okasha E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 16) Title: “Second International Conference, South Asian

Association for Regional Cooperation (SAARC) Psychiatric Federation”

Place: Kathmandu, Nepal Date: November 17–19, 2006 Organizer: South Asian Association for Regional Cooperation

(SAARC) Psychiatric Federation” Collaboration: Psychiatric Association of Nepal Contact: a) Professor Mahendra K. Nepal

b) Professor Roy Abraham Kallivayalil E-mail: a) [email protected]

b) [email protected]


WPA CO-SPONSORED CONFERENCE (Zone 12) Title: “Regional Meeting of the Royal College of

Psychiatrists (Middle East Division)” Place: Beirut, Lebanon Date: November 23–25, 2006 Organizer: Middle East Division, Royal College of Psychiatrists Contact: Dr. Fuad T. Antun E-mail: [email protected] WPA SPONSORED REGIONAL MEETING (Zone 4) Title: WPA Regional Meeting Place: Lima, Peru Date: November 30–December 3, 2006 Organizer: Peruvian Psychiatric Association Contact: Dr. Marta Rondon @ Dr. Gabriela Kuroiwa E-mail: [email protected]

2007.

WPA SPONSORED REGIONAL MEETING (Zone 9) Title: “WPA Regional Meeting” Place: Budapest, Hungary Date: January 23–24, 2007 Organizer: Hungarian Psychiatric Association Contact: Dr. Tury Ferenc E-mail: [email protected] Website: www.mpt.iif.hu WPA SPONSORED SECTION MEETING (Zone 11) Title: “Psyche and Art Seminar” Place: Djerba, Tunisia Date: February 13–16, 2007 Organizer: WPA Section on Art and Psychiatry Collaboration: Schattauer Verlag Publishers Contact: Dr. Hans Otto Thomashoff E-mail: [email protected] WPA SPONSORED REGIONAL MEETING (Zone 13 & 14) Title: “WPA Regional Meeting” Place: Nairobi, Kenya Date: March 22–24, 2007 Organizer: Kenya Psychiatric Association Contact: Dr. Frank G. Njenga E-mail: [email protected]


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WPA SPONSORED SECTION MEETING (Zone 11) Title: “Third International Congress on Hormones, Brain

and Neuropsychopharmacology” Place: Marrakech, Morocco Date: April 22–25, 2007 Organizer: WPA Section on Interdisciplinary Collaboration Contact: Dr. Uriel M. Halbreich E-mail: [email protected] WPA SPONSORED REGIONAL MEETING (Zone 17) Title: “WPA Regional Meeting” Place: Seoul, Korea Date: April 18–21, 2007 Organizer: Korean Neuropsychiatric Association Contact: Dr. Young-Cho Chung E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 10) Title: “15th World Congress of the World Association for

Dynamic Psychiatry” Place: St. Petersburg, Russia Date: May 16–19, 2007 Organizer: World Association for Dynamic Psychiatry Contact: Dr. Monika Dworschak E-mail: [email protected] WPA SPONSORED THEMATIC CONFERENCE (Zone 9) Title: WPA Thematic Conference “Coercive Treatment

in Psychiatry: A Comprehensive Review” Place: Dresden, Germany Date: June 6–8, 2007 Organizer: Eunomia Study Group Contact: Prof. Thomas Kallert E-mail: [email protected] Website: www.eunomia-study.net WPA CO-SPONSORED CONFERENCE (Zone 3) Title: VI Simposio Internacional “Aspectos Biologicos y

Farmacoterapeuticos de los Transtornos Mentales” Place: Habana, Cuba Date: June 18–22, 2007 Organizer: “Cologio Cubano de Neuropsicoframacologia” Collaboration: Cuban Society of Psychiatry Contact: Dr. Jose Perez Milan E-mail: [email protected]


WPA CO-SPONSORED CONFERENCE (Zone 8) Title: “13th International Congress of the European Society

for Child and Adolescent Psychiatry” Place: Florence, Italy Date: August 25–29, 2007 Organizer: European Society for Child and Adolescent

Psychiatry Contact: Cecilia Sighinolfi E-mail: [email protected] Website: www.escap-net.org WPA SPONSORED REGIONAL MEETING (Zone 17) Title: “WPA Regional Meeting” Place: Shangai, China Date: September 20–23, 2007 Organizer: Shangai Mental Health Center Contact: Dr. Zeping Xiao E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 9) Title: “Annual Meeting of the Psychiatric Association of

Serbia and Montenegro” Place: Novi Sad, Serbia and Montenegro Date: October 4–7, 2007 Organizer: Psychiatric Association of Serbia and Montenegro Contact: Dr. Dusica Lecic Toseviski E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 9) Title: “XIX World Association for Social Psychiatry

Congress” Place: Prague, Czech Republic Date: October 21–25, 2007 Organizer: World Association for Social Psychiatry Contact: Dr. Shridhar Sharma E-mail: [email protected] WPA CO-SPONSORED CONFERENCE (Zone 11) Title: “Annual Meeting of the International Society Of

Addiction Medicine (ISAM)” Place: Cairo, Egypt Date: October 23–28, 2007 Organizer: International Society of Addiction Medicine (ISAM) Collaboration: WPA Section on Addiction Psychiatry Contact: Dr. Nady El-Guebaly E-mail: [email protected]


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WPA SPONSORED REGIONAL MEETING (Zone 5) Title: “XIV Congress of the Argentinean Association of

Psychiatrists” Place: Buenos Aires, Argentina Date: October 24–26, 2007 Organizer: Argentinean Association of Psychiatrists (AAP) Contact: Dr. Nestor F. Marchant E-mail: [email protected] Website: www.aap.org.ar WPA SPONSORED INTERNATIONAL CONGRESS (Zone 18) Title: “WPA International Congress” Place: Melbourne, Australia Date: November 28–December 2, 2007 Organizer: Royal Australian and New Zealand College of

Psychiatrists (RANZCP) Contact: Sharon Brownie E-mail: [email protected] Website: www.ranzcp.org

2008. WPA SPONSORED THEMATIC CONFERENCE (Zone 8) Title: “WPA Thematic Conference on Depression and

Relevant Psychiatric Condition in Primary Care” Place: Granada, Spain Date: June 19–21, 2008 Organizer: Spanish Society of Psychiatry Contact: Dr. Francisco Torres E-mail: [email protected] WPA SPONSORED WORLD CONGRESS OF PSYCHIATRY (Zone 9) Title: “XIV World Congress of Psychiatry” Place: Prague, Czech Republic Date: September 19–25, 2008 Organizer: Czech Psychiatric Association Collaboration: World Psychiatric Association Contact: Dr. Jiri Raboch E-mail: [email protected]

2009. WPA SPONSORED INTERNATIONAL CONGRESS (Zone 8) Title: “Treatments in Psychiatry: A New Update” Place: Florence, Italy Date: April 1–4, 2009 Organizer: Italian Psychiatric Association Contact: Dr. Mario Maj E-mail: [email protected] Website: www.psichiatria.it


2010. WPA SPONSORED REGIONAL MEETING (Zone 17) Title: “WPA Regional Meeting” Place: Beijing, China Date: September 1–5, 2010 Organizer: Chinese Society of Psychiatry Contact: Dr. Yizhuang Zou E-mail: [email protected] Website: www.psychiatryonline.cn

2011. WPA SPONSORED WORLD CONGRESS OF PSYCHIATRY (Zone 5) Title: “XV World Congress of Psychiatry” Place: Buenos Aires, Argentina Date: August or September 2011 Organizer: a) Argentina Association of Psychiatrist (AAP)

b) Association of Argentinean Psychiatrists (APSA) c) Foundation for Interdisciplinary Investigation of Communication (FINTECO)

Contact: Mariano R. Castex E-mail: [email protected] Website: www.congresosint.com.ar


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WEBSITE American Psychiatric Association (APA) http://www.psych.org/ American Psychological Association http://www.apa.org/ Anonimni alkoholičari www.anonimnialkoholicari.org Borderline and Beyond: Borderline and Beyond: A Program of Recovery from Borderline Personality Disorder (BPD) http://www.laurapaxton.com/ Borderline Personality Disorder Central http://www.bpdcentral.com/ Borderline Personality Disorder Research Foundation (BPDRF) New York State Psychiatric Institute http://www.borderlineresearch.org/ Borderline Personality Disorders, Richard J. Corelli, M.D. www.stanford.edu/~corelli/borderline.html Borderline Sanctuary http://www.mhsanctuary.com/borderline/ Center for Mental Health Services – Substance Abuse and Mental Health Services Administration http://www.samhsa.gov/ Elektronsko izdanje časopisa Sociološki pregled www.socioloskipregled.org.yu Human Rights Tools http://www.humanrightstools.org/index.htm Institutu za zaštitu zdravlja Srbije www.batut.org.yu International Society for the Study of Personality Disorders (ISSPD) http://www.isspd.com/ Intervention – The International Journal of Mental Health, Psychosocial work and Counselling in Areas of Armed Conflict http://www.interventionjournal.com IRCT – International Rehabilitation Council for Torture Victims http://www.irct.org/


ISSPD – International Society for the Study of Personality Disorders http://www.isspd.com/ Journal of Personality Disorders (Periodicals – Psychology) http://www.guilford.com/ Lippincott, Williams and Wilkins http://www.lww.com National Institute of Mental Health (USA) http://www.nimh.nih.gov/ Obsessive Compulsive Foundation http://www.ocfoundation.org/ OCD Resource Center of South Florida http://www.ocdhope.com/ Oficijelni sajta Zdravstvenog centra Bor www.zcbor.org.yu PILOTS Index to Traumatic Stress Literature http://www.ncptsd.va.gov/publications/pilots/ Sexual Offender Treatment – a new journal: scientifically based, practice oriented, useful – online and free of charge. The second issue is available now: http://www.sexual-offender-treatment.org Treatment and Research Advancements, Association for Personality Disorder (TARA APD) http://www.tara4bpd.org/ World Federation of Societies of Biological Psychiatry (WFSBP) www.wfsbp.org World Psychiatric Association (WPA) http://www.wpanet.org/ WPA ONLINE – Electronic Bulletin, June 2006 http://www.wpanet.org


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Institut za mentalno zdravljePalmoti eva 37, 11000 Beograd, Srbija

Tel/faks 3236-353, 3226-925ć

www.imh.org.rs

Institute of Mental HealthPalmoticeva 37, 11000 Belgrade, Serbia

Tel/fax 3236-353, 3226-925www.imh.org.rs

Documents

Psihijatrija danas 2005-2